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OPERATIVE OBSTETRICS 



INCLUDING 



THE SURGERY OF THE NEWBORN 



BY 

EDWARD P. DAVIS, A.M., M.D. 

Professor of Obstetrics, Jefferson Medical College ; Obstetrician to the Jefferson Hospital; Obstetrician 
and Gynecologist to the Philadelphia Hospital ; Consultant to the Preston Retreat; Member 
of the American Gynecological Society, International Congress of Obstetrics and 
Gynecology', College of Physicians of Philadelphia ; Honorary Mem- 
ber of the Chicago Gynecological Society, Medical Society 
of the State of Virginia, Academy of Surgery of 
Bucharest, Ophthalmological Society of Egypt, etc. 



IVITH 264 ILLUSTRATIONS 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1911 



> 
o, 






Copyright, 191 1, by W. B. Saunders Company 



< 9 s 
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PRINTED IN AMERICA 



PRESS OF 
SAUNDERS COMPANY 
PHILADELPHIA 



CI.A297739 . 



PREFACE 



The recent development of obstetric surgery has reached a point 
where it seemed to the writer that a concise statement of methods of 
operating in obstetrics at the present time might be of service to the 
profession. The effort has been made to condense the subject matter, 
BibHographies have been added for the convenience of those who may 
wish to consult the literature. 

The writer desires to express his thanks for permission, given by 
recent writers upon the subject, to reproduce their illustrations. 

E. P. D. 

250 South Twenty-first Street, 

Philadelphia, Pa. 
September, 1911. 

11 



CONTENTS 



PAGE 

Introduction 17 

Anatomy 17 

The Condition of the Birth-canal Regarding Asepsis 24 

Conditions Preventing and Controlling Hemorrhage in Normal Labor . 27 

The Pregnant Woman as a Surgical Patient 28 

Obstetric Anesthesia 29 

The Technic of Obstetric Surgery 39 

Obstetric Operations in Hospitals 39 

To Conduct Obstetric Operations in Private Houses 45 

Assistants for Obstetric Operations 49 



PART I 

The Surgery of Pregnancy . .51 

Uterine Displacements 51 

Repair of Lacerations of the Uterus During Pregnancy 56 

The Removal of Uterine Tumors During Pregnancy 56 

Operations upon the Fallopian Tubes and Ovaries 62 

Operations upon the Pelvic Floor and Perineum During Pregnancy 65 

Operations upon the Rectum During Pregnancy 66 

Emptying of the Uterus Before Viability; Therapeutic Abortion 66 

Emptying the Uterus after Viability and Before Full Term; The Induction 

of Labor 69 

Rapid and Forcible Dilatation of the Womb 89 

Operation for Appendicitis 93 

Cholecystotomy in Pregnancy 96 

Operations upon the Kidneys During Pregnancy 97 

Abdominal Section During Pregnancy 99 

Operation for Ectopic Gestation 100 



PART II 



The Surgery of Labor 117 

The Extraction of the Child Through the Vagina 117 

Manual Extraction of the Fetus Through the Vagina 130 

13 



14 CONTEXTS 



PAGE 



Delivery by Forceps 163 

Version 210 

Embryotomy 237 

Vaginal Extraction Preceded by Enlargement of the Birth-canal 257 

Postural Enlargement 257 

Section of the Pelvis 261 

- Symphyseotomy 261 

Pubiotomy . . . ; 267 

Vaginal Extraction Preceded by Section of the Cervix, Lower Uterine Seg- 
ment, or Perineum 287 

Incision of the Cervix 287 

Vaginal Cesarean Section 289 

Incision into the Pelvic Floor and Perineum 299 

Delivery by Abdominal Section 300 

Celiohysterotom}' 301 

Delivery by Abdominal Section with Sterihzation 314 

Celiohysterectomy with Intrapelvic Treatment of the Stump 315 

Celiohysterectomy with Extraperitoneal Treatment of the Stump 

(Porro's Operation) 320 

The Results of Delivery by Abdominal Section in the Writer's Ex- 
perience 327 

The Treatment of Rupture of the Uterus 328 

Total Extirpation of the Pregnant Womb 330 

Suprasymphyseal Section 333 

Extraperitoneal Section by Inguinal Incision 341 

Rupture of the Uterus 349 

Inversion of the Uterus 359 



PART III 



The Surgery of the Puerperal Period 365 

The Removal of the Placenta 365 

The Control of Hemorrhage During Labor 371 

The Control of Hemorrhage after Labor (Postpartum Hemorrhage) 376 

Placenta PrcTvia 390 

Premature Detachment of Normally Implanted Placenta 397 

The Immediate Repair of Lacerations of the Genital Tract : 401 

The Intermediate Repair of Lacerations of the Genital Tract 413 

The Late Repair of Lacerations of the Generative Tract 414 

The Correction of Uterine Displacements Following Labor, With or Without 

Lacerations 419 

Diastasis of the Recti Muscles and Relaxation of the Abdominal Wall 

Following Labor 422 

The Technic of Operations for the Repair of Lacerations and the Correction 

of Displacements 422 

The Surgery of Puerperal Septic Infection 424 

Puerperal Mastitis 436 



CONTENTS 15 

PART IV 

PAGE 

The Surgery of the Newborn 441 

Asphyxia 441 

Umbilical Hemorrhage 442 

Umbilical Hernia 443 

The Surgical Treatment of Fractures in the Newborn 444 

The Surgical Treatment of Brachial Palsy in the Newborn 449 

Injuries to the Scalp 453 

Lesions of the Face and the Organs of Special Sense 4o6 

Congenital Lack of Development 458 

The Surgical Treatment of Infection in the Newborn 459 

Circumcision 460 



Index 465 



OPERATIVE OBSTETRICS 



INTRODUCTION 



ANATOMY 

The Anatomy of the Birth -canal During Pregnancy. — The intel- 
ligent performance of obstetric operations requires practical knowl- 
edge of the anatomy of the birth-canal during the various periods 
of gestation. 

Position of the Womb During Development. — In the majority of 
cases the womb is anteverted and slightly anteflexed at the begin- 
ning of pregnancy. After the first few weeks the body of the womb 
becomes globular, but steadily maintains a slightly anteverted posi- 
tion. In thin subjects the fundus can plainly be felt through the 
abdominal wall behind the pubes at from four to six weeks. In 
stout patients the fundus may not be distinguished until eight or 
nine weeks have passed. 

So freciuent are retroflexions and anteflexions that the obstet- 
rician is often called upon to operate in early pregnancy under 
these conditions. 

In retroflexion the body of the womb enlarges steadily, and, in 
proportion as retroflexion is complete, spreads in the pelvis from side 
to side, in extreme cases fitting itself closely under the promontory 
of the sacrum. The degree of pressure made by the growing w^onib 
will depend upon the size of the pelvis and relative size of the womb. 
In a capacious pelvis the body of the w^omb very slowly assumes a 
more or less globular shape with but httle pressure. Where the 
pelvis is small, considerable pressure develops early. The rise of the 
retroflexed gravid womb depends greatly on freedom from abdominal 

2 17 



18 OPERATIVE OBSTETRICS 

pressure. Where the patient is recumbent, and the urinary bladder 
is not allowed to fill sufficiently to make pressure, a retroflexed womb 
rises spontaneously in the great majority of cases. 

In cases of extreme retroflexion in anemic, flabby young patients, 
the womb may be so soft as to simulate very closely an extravasa- 
tion of blood or collection of pus in Douglas' cul-de-sac. 

In anteflexion of the pregnant womb the fundus is bent sharply 
forward, and womb, tubes, and ovaries are pressed downward, the 
bladder is forced downward with the womb, and the condition is 
accompanied by spasm of the pelvic muscles, which may be termed 
pelvic tenesmus. 

Size of the Womb During Development. — The size of the womb 
during pregnancy will depend greatly upon the stature and develop- 
ment of the patient, the size of the fetus, and the general vigor of 
the mother. In the average patient when the fundus can be recog- 
nized by abdominal pressure the patient is six weeks advanced. At 
twelve weeks the fundus is little less than midway between the pubes 
and the umbiUcus. At twenty-four weeks the fundus has reached 
the umbilicus. At twenty-eight weeks it is two fingers above. At 
thirty-two weeks, a hand's breadth. At thirty-six wrecks, once and 
a half the breadth of the ordinary hand. 

In primiparse signs of descent and engagement become evident 
from the thirty-fifth week on, in proportion to the relative size of 
mother and child. Where sUght disproportion exists, the mother's 
general condition good, the action of the uterine and abdominal 
muscles brings the child into the upper pelvis comparatively early. 
In multiparse the fetus will remain above the pelvic brim indefiniteh', 
in proportion to the size of the pelvis and the firm or relaxed condition 
of the mother's tissues. 

Bibliography of Uterus During Development 

Alfieri: AnnaH di Ostetricia, No. 1, 1903. 

Blacker : Transactions of the Obstetrical Society of Tendon, p. 235, 1900. 
Czyzewicz: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 25, 
p. 785, 1907. 



ANATOMY 



19 



von Fellonberi.^: Arcliiv f. ( iynak()l()<i;i(\ l^and 71, Heft 2, 1904. 
FeiToni: Annali di Osteliicia. (October and Xoveinbcr, 1902, and No. 8, 

1902. 
Haultein: B^iti^^ll Medical Journal, p. 1279, 1900. 
Kleinwiichter: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 4, 

Heft 1, 1S99, and Band 41, Heft 3, 1S99. 
Xikolic: Zentralblatt f. Gynakologie, Xo. 3, 1900. 
Piskacek: Monatsschrift f. (ieburtshiilfe imd Gynakologie, Band 13, 

Heft 3, 1901. 
Stephenson: Scottish Medical Journal, January, 1905. 

The Position of the Womb During Labor. — At viability and after, 
in the presence of labor, the birth-canal becomes a continuous channel, 




Fig. 1. — Frozen section of primipara dying in labor. 

iBumm and Blumreichi. 



First position of vertex 



whose axis is directed first downward and backward, then upward 
and forward. As uterine contractions develop the round Hganients 
contract, drawing the fundus forwai'd over the pelvic brim. The 
contraction of the abdominal muscles helps in maintaining this posi- 
tion, the combined action of uterus and abdominal muscles forcing 



20 



OPERATIVE OBSTETRICS 



the fetus downward. In introducing instruments into the womb 
during labor, the operator must remember the anterior position of 
the body of the womb. In unskilful operations instruments have 
been forced through the posterior vaginal fornix, cervix, and lower 
uterine segment, the operator supposing that he was carrying the 
instrument into the womb. 



Contraction-ring 



Attachment of 

membranes 

Promontory! 

Internal os 

External os. 




Contraction-ring 



Contraction-ring 
Attachment of 
membranes 

} Internal os 



vExternal os 



Fig. 2, — Frozen section of woman dying in labor. Head on pelvic floor ; contrac- 
tion-ring high up posteriorly (Bumm and Blumreich). 

The position of the womb during labor is influenced somewhat by 
the mechanism of labor; the posterior portion of the lower uterus 
and the vagina are carried backward by posterior rotation of the 
occiput. In shoulder presentations the womb is abnormally dis- 
tended and its characteristic position is lost. This is also true in 
cases where operations for fixation of the uterus have been per- 
formed. 

The expulsion of the placenta, membranes, and cord occurs in 
what is practically a second labor. The fundus remains forward dur- 



ANATO.MY 21 

ing tlio third stage and the axis of the birth-canal is i)ractically the 
same as that of the second stage of hdjor. 

The Pelvic Floor, Vagina, and Perineum During Labor. — In spite 
of the differences of opinion as to what constitute the supports of 
the uterus, and exactly what is meant by the pelvic floor, for prac- 
tical purposes Hart's division of the pelvic floor into anterior and 
posterior segments will be found of practical value. The axis of the 
uterus meets the pvWk Hoor near the sacrococcygeal junction; in 
proportion to the strength and development of the levator ani muscle, 
the axis is thence turned upward and forward beneath the pubes. 
The posterior segment of the pelvic floor during labor exerts inter- 
mittent pressure upon the presenting part, forcing it toward the outlet, 
and causing, when such is possible, rotation. Remembering this 
important function in forceps operations, the head is brought strongly 
down upon the pelvic floor, where rotation is incomplete, with the 
hope that, by this aid, rotation may be accompHshed. 

The anterior segment of the pelvic floor, comprising the anterior 
vaginal wall, the urethra and tissues about it, is drawn strongly up- 
ward during the expulsion of the child, the function seeming to be to 
withdraw the urethra and neck of the bladder as much as possible 
from injury. 

Bibliography of Pelvic Floor, Vagina, axd Perineum: Anatomy 

AND Functions of 
Paramore: Journal of Obstetrics of the British Empire, February, 

1909; March, 1909. 
Studdiford: American Journal of Obstetrics. July, 1909. 

Bibliography of the Anatomy of the Birth-canal During 

Pregnancy 
AschofT: Berliner klin. Wochens., No. 31, 1907. 
Bayer: Beitrage f. Geburtshiilfe u. Gynakologie, Bd. 14, Hft. 3, 1909; 

also Bd. 15, Hft. 2, 1909. 
Bumm and Blumreich: Atlas, Wiesbaden, Bergmann, 1907. 
Gauss: Miinchener med. Wochens., p. 440, 1907. 
Hofbauer: Monats. f. Geburts. und GynakoL, Bd. 29, Hft. 2, 1908. 
Meyer: Surgery, Gynecology, and Obstetrics, May 5, 1907. 



22 OPERATIVE OBSTETRICS 

Position of the Womb After Labor. — If recovery from labor is 
normal, the womb assumes a slightly ant evert eel position, arising in 
the abdomen until the fundus is near the umbilicus. It can be dis- 
tinctly made out by palpation, its contractile portion firm and hard, 
while the lower segment and the stretched and torn surfaces in the 
cervix have fallen together. The stretched condition of the pelvic 
and vaginal tissues allows the cervix to descend into the pelvic brim, 
and if the urinary bladder be empty and a binder appUed pinned from 
above downward, the fundus is carried forward, the uterus descends 
slightly into the pelvic brim, and pressure is thus made upon the uter- 
ine and ovarian arteries by the pelvic brim and tissues. As involu- 
tion proceeds this position is maintained. Where, because of in- 
fection, hemorrhage, or prostration, the womb is not firm after labor, 
it may be retro verted or dilated by blood-clot, not assuming its ante- 
verted position, and sinking backward and downward into the 
abdominal cavity. 

Factors Producing Normal Involution and Return to Normal 
Position After Labor. — It is important that the obstetrician keeps in 
mind the essential factors producing a return of the birth-canal to 
its normal condition after labor. 

First in importance is the absence of infection. In septic metritis 
the uterine muscle does not contract properly, the womb remains 
large and flabby; if the infection be severe, the canal is softened and 
the uterus is very readily perforated, infection extending to the broad 
ligaments and the tissues about the cervix, causing the cervix to 
assume an unnatural position producing displacements. When the 
patient recovers from acute infection, exudates and adhesions may 
permanently alter the position of the womb. 

Laceration of the birth-canal which is not adequately repaired is 
a most efficient factor in preventing a return to the normal condition 
of the birth-canal. Where infection follows laceration the results are 
worse than in uncomplicated cases. 

The general vigor or lack of strength in the patient, her ability 
to nurse the child, the care which she receives during the puerperal 



AXATOMY 23 

period, th(^ avoidance of constipation, all the conditions which bi'ing 
abont a ])ronipt n^turn to health, are most potent in j)roducing a 
good recovery from labor. It must not be forgotten that abdomi- 
nal pressure by improper clothing may produce displacenK^nt of the 
womb in cases which liave been normal until ordinary clothing was 
resumed. 

Bibliography 
Alvensleben: Zentralblatt f. Gynakologie. Xo. 36, 190S. 
Burkhard: Zeitschrift f. (ieburtshiilfe und Gj'nakologie, Band 51, Heft 

1. 1904. 
Flint : American Journal of Obstetrics, January, 1908. 

Bladder and Rectum During and After Labor. — As the presenting 
part descends into the pelvis, if the child fits tightly and dispropor- 
tion be present, the neck of the bladder is pressed down between the 
presenting part and the symphysis, its mucous membrane becomes 
congested, and blood may be present in the urine. This is seen in 
cases of contracted pelvis, where the patient is for some time in 
ineffectual labor before assistance is rendered. The obstetrician 
should remember to invariably employ a catheter in all cases before 
operating. Bloody urine is a sign of prolonged labor with dispro- 
portion and excessive birth pressure. 

The rectum is also subjected to pressure in cases where dispro- 
portion exists and the discharge of the child is difficult. During 
prolonged labor the mucous membrane will becom^e everted at the 
anus, and hemorrhoids, if present, will become greatly distended. A 
rectum impacted with hardened feces is an obstacle to the descent 
of the child, and hence the invariable rule that both bladder and 
rectum should be emptied before undertaking an obstetric operation. 

The Abdomen During Pregnancy. — As the operator may be called 
upon to perform abdominal section during pregnancy, it is well to 
keep in mind the anatomic relations. 

As the womb gi'ows and extends upward the intestines will be 
pushed upward and toward the sides. The degree of intestinal dis- 
tention will depend not only upon the mechanical pressure, but also 



24 OPERATIVE OBSTETRICS 

upon the toxemic condition of the patient. Headache and intestinal 
toxemia are often accompanied by the formation of large quantities 
of gas. In these cases the transverse colon may become so distended 
as to obscure the palpation of the fundus and render a diagnosis of 
the size of the uterus difficult. The stomach may also be distended, 
and both stomach and intestines will cause excessive tympany and 
may obscure the recognition of fetal heart sounds. 

If the patient has had general prolapse of the abdominal viscera, 
this condition will be partl}^ removed by pregnancy. A prolapsed 
and floating kidney will be pushed upward as pregnancy advances to 
term. A dislocated spleen has in some instances been pushed upward, 
while in other cases it has been found low in the abdomen. The 
appendix vermiformis may be drawn upward as the w^omb rises if 
adhesions have been present between the appendix and surrounding 
tissues. In some cases it is pushed downward to or below the brim 
of the pelvis by the pressure of the womb above. Except in very 
fat patients, the abdominal wall becomes greatly thinned in preg- 
nancy, and in prolonged labor the bladder is drawn strongly upward, 
and may be opened by the operator's knife in performing abdomi- 
nal section, if caution is not observed. The abdominal viscera are 
unusually full of blood, the peritoneal tissues congested, and, in 
prolonged labor, fluid is found in the peritoneal sac. 

Bibliography 

Bumm and Blumreich: Account of Frozen Section, Weisbaden, J. F. 

Bergmann, 1907. 
Fellner: Zentralblatt f. Gynakologie, No. 22, 1906. 
Filth: Archiv f. Gynakologie, Band 76, Heft 3, 1907. 
Heil: Archiv f. Gynakologie, Band 81, Heft 1, 1907. 

THE CONDITION OF THE BIRTH-CANAL REGARDING ASEPSIS 

After prolonged discussion concerning the presence of bacteria 

in the birth-canal during pregnancy, the following conclusions seem 

to have been established by the majority of observers: In a healthy 

patient bacteria are found in greater or less abundance in the vagina, 



THE COXDITIOX OF THE BIKTH-CANAI. inXJARDING ASEPSIS 25 

ami (^specially about its (Mitraiicc during i)r(^gnancy. Streptococci, 
staphylococci, the J^acillus coli coinniunis, the j)ncuniococcus, and 
lower forms of bacteria of l(>ss(^r ^■irulellce may be present in perfectly 
healthy individuals. These bacteria may enter the cervix, but ordi- 
narily do not i)ass within the uterine cavity or between the mem- 
branes and the wall of the womb. In spontaneous parturition the 
movement of the uterine contents is from above downward, and the 
tendency is to sweep bactc^ria out of the vagina rather than into the 
uterus. During pregnancy the patient is protected from vaginal bac- 
teria by the vaginal mucous secretion, which is somewhat germicidal, 
by the integrity of the vaginal mucous membrane, and the resist- 
ing qualit}^ of the blood. After labor, bacteria may ascend into the 
empty uterus, and often do so in cases presenting no abnormal symp- 
toms. Even under such circumstances, if the womb be tightly con- 
tracted, the patient sound physically, and her blood in good con- 
dition, mfection may not develop. 

When, however, bacteria are carried into the uterus as an ac- 
companiment to prolonged interference with the introduction of the 
hand and instruments, with laceration of the cervix and wounding of 
the endometrium, they produce infection. This is especially apt to 
happen in cases where fruitless efforts are made at delivery, with 
more or less pause between these efforts. In operations properly 
performed and promptly completed, although bacteria may enter the 
uterus at the time of operation, if the womb be left tightly con- 
tracted without accumulation of blood-clot or retained placenta, the 
conditions are not favorable for their development. 

In cases w^here infections occur in the pelvic floor or vagina, 
bacteria ascend within the womb; if, however, the uterus be tightly 
contracted they often produce no symptoms and do no harm. Lab- 
oratory research and clinical observations lead us to believe that it is 
not mereh^ the presence of bacteria in the vagina or uterus which is 
most dangerous to the patient, but the bruised and necrotic condition 
of the tissues following difficult extraction and prolonged labor, and 
the anemia of the mother resulting from hemorrhage and exhaustion. 



26 OPERATIVE OBSTETRICS 

These considerations suggest the question, ''What shall be done 
to prepare the birth-canal for obstetric operations? " Shall an effort 
be made by vigorous antisepsis to remove all bacteria, giving the opera- 
tor a sterile field for his operation? Clinical experience shows that, 
while this may theoretically be desirable, it is not practical. Ac- 
cumulated secretions harboring bacteria and blood-clot should be 
removed before obstetric operations in the gentlest manner possible, 
and with antiseptic agents which do not cause necrosis of the vaginal 
epitheha. In place of vigorous rubbing with cotton or gauze, a copious 
but gentle douche, with a mild alkali combined with an antiseptic, 
gives the best result. In prolonged interference, as in induced labor, 
ascent of bacteria into the womb may be hindered by tamponing 
wuth iodoform gauze. In view of the constant presence of bacteria 
in the vagina and about the cervix, lacerations occurring during 
labor should be closed as promptly as possible. 

The presence of preexisting infection, as gonorrhea or syphilis, 
renders the birth-canal septic for purposes of operation. In such 
cases every care must be taken to interfere as little as possible with the 
interior of the womb, and to leave the uterus in such condition after 
operation that the spread of infection will be minimized. 

Bibliography 

Briinings: Monatsschrift f. Geburtshiilfe und Gynakologie, p. 533, 1900. 

Bugelsdorff : Archiv f. Gynakologie, Band 78, Heft 3, 1906. 

Conrad: Beitrage f. Geburtshiilfe u. Gynakologie, Bd. 13, Hft. 3, 1909. 

Fritsch: Deutsche m. Wochen., No. 8, 1909. 

Gottschalk: Zent. f. Gynakologie, p. 1611, 1909. 

Higuchi: Archiv f. Gynakologie, Bd. 86, Hft. 3, 1909. 

Hofbauer: Monatssch. f. Geburts. und Gynakol., Bd. 29, Hft. 2, 1908. 

Hofmeier: Zent. f. Gynakologie, p. 1493, 1909. 

Jung: Zeitschrift f. Geburts. u. Gynakol., Bd. 64, Hft. 3, p. 505, 1909. 

Kehrer: Monatssch. f. Geburts. und Gynakol., Bd. 89, Hft. 3, 1909. 

Perry: L'Obstetrique, January, 1907. 

Pfeilsticker: Gyn. Rundschau, p. 440, 1909. 

Sticher: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 44, Heft 1, 

1900. 
Zweifel : Archiv f . Gynakologie, Band 86, Heft 3, 1908. 



CONDITIONS rHEVEXTlNd HK.MOHHHAdK I\ NORMAL LABOR 2/ 

CONDITIONS PREVENTING AND CONTROLLING HEMORRHAGE IN 

NORMAL LABOR 

Obstetric operations, like otlier surgical procedures, are (lan^(M*ous 
because of the possibility of the occurrence of hemorrhage, septic 
infection, and shock. In the delivery of the fetus the gi'eat(\st im- 
portance may be ascribed to the presence or absence of uterine con- 
tractions. In cases of profound inertia, where the fetus is forcibly 
removed, violent hemorrhage often follows. The delivery of the 
child during uterine contractions not only does not produce hem- 
orrhage, but brings about a prompt and permanent contraction 
of the uterus. As uterine contraction is a most efficient means of 
preventing hemorrhage, obstetric operations should, if possible, be 
performed while the uterus is active. Should inertia be present, 
stimulation should first be resorted to to produce uterine action be- 
fore the fetus is removed. 

In spontaneous parturition, hemorrhage is prevented by the de- 
scent of the lower portion of the w^omb into the pelvic brim, causing 
pressure upon the blood -supply of the uterus. Hemorrhage is also 
prevented by the condition of the patient's blood, which, in the absence 
of anemia, stimulates the uterine muscle to contraction and main- 
tains a tonic condition in the nervous centers. In usual labor the 
absence of dangerous lacerations prevents extensive hemorrhage. 
The absence of infection is also a potent safeguard against the de- 
velopment of hemorrhage. 

If the operator would avoid hemorrhage, he must secure uterine 
contraction, both during his operation and afterward; he must stim- 
ulate not only the uterine muscle, but the nervous system of the 
patient, as indications arise, and be prepared to repair lacerations 
causing hemorrhage as soon as possible. As in other branches of 
surgery, his constant endeavor will be to avoid infection. 

Bibliography 

Carmichael: British Medical Journal, February 24, 1906. 
Dietzmann: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 17, 
Heft 3, 1903. 



28 OPERATIVE OBSTETRICS 

Fellner: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 16, Heft 

5, 1902. 
Ferroni: Annali di Ostetricia, No. 10, 1899. 
Fiith: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 51, Heft 2, 

1904. 
Given: Journal of Obstetrics of the British Empire, April, 1906. 
Henderson: Journal of Obstetrics of the British Empire, February, 

1902. 
Hermann: British Medical Journal, June 16, 1906. 
Marshall: British Medical Journal, May 2, 1903. 

Sachs: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 63, Heft 1. 
Savare: Annali di Ostetricia, No. 11, 1904. 
Schroeder: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 17, 

Heft 5, 1903. 
Sfameni: Annali di Ostetricia, November, 1899. 
Zangemeister : Zeitschrift f. Geburtshiilfe unci Gynakologie, Band 49, 

Heft 1, 1903. 

THE PREGNANT WOMAN AS A SURGICAL PATIENT 

Pregnancy was formerly considered, if not a positive contraindi- 
cation, an unfavorable condition for surgical procedures. Experience 
has shown that this view is an exaggerated one, and that it is possible 
to perform surgical operations of magnitude upon pregnant patients 
with satisfactory results. 

Among the conditions which often render pregnant women bad 
subjects for surgical interference the most important is the toxemia 
of pregnancy. In proportion as this is severe, hemorrhage after an 
operation may be uncontrollable, shock will develop rapidly, anes- 
thesia may be followed by overwhelming toxemia, and the reaction 
of the patient is very feeble. Before operating, surgeons should ex- 
amine a pregnant patient carefully to determine the presence or ab- 
sence of toxemia. The ordinar}^ examination of the urine is not decis- 
ive in such a case. A twenty-four-hour specimen should be obtained, 
and, if possible, in addition to other examination, a nitrogen parti- 
tion should be made. If there is a prolonged toxemia during preg- 
nancy the patient will be anemic, with altered pulse tension and a 
good subject for hemorrhage. 



OBSTETRIC ANESTHESIA 29 

The nervous system of the |)i'('<iiuiiit patient is in a more or less 
excitable condition, and this is csixH-ially seen in the tendency to 
emptying of the uterus. U this he ])revented the pregnant 
patient will usually recover \\v\\ after opc^ration. 

Anesthesia for surgical operations during pregnancy requires 
especial care because the enlarged uterus makes res]:>iration difficult, 
and there is a constant t(^nd(aicy to pulmonary congestion and to 
overburdening the right heail. 

"Where, however, the pregnant })atient is not toxic, is not fat, 
with good circulation and normal blood tension, and without bron- 
chial irritation, she will endure surgical procedures in a veiy satis- 
factory manner. If the emptying of the uterus be prevented her 
recovery from operation is usually satisfactoiy. 

BlBLIOGRAPIiy 

Chi-ist: Zentralblatt f. Gynakologie, Xo. 16. 1901. 
Joubert: Thesis, Paris. Xo. 317, 1906 and 1907. 
Marscliner: Zentralblatt f. Gynakologie, Xo. 38, 1902. 
Xeu: Archiv f. Gynakologie. Band SO, Heft 2, 1906. 
Schauta: Zentralblatt f. G^'nakologie, Xo. 25, 1906. 
Thring: British Medical Journal, January 9, 1904. 

OBSTETRIC ANESTHESIA 

Anesthesia for obstetric operations should be conducted with the 
same care which is given to the administration of anesthetics in other 
surgical procedures. The careless and inefficient way in which anes- 
thetics are given in many confinements has had much to do with some 
of the obstetric disasters which occasionally occur. It is true that 
obstetric practice is conducted under unusual difficulties, from its 
irregularity, and from the fact that so little of it can be done in 
hospitals; but more patients are confined in hospitals than was for- 
merh' the case, and careful operators are accustomed to take with 
them to private houses competent anesthetizers. 

An anesthetizer for obstetric operations must be competent to 
use ether and chloroform. It will be well if he has had experience 
with ethyl chlorid and nitrous oxid. Anesthesia by lumbar injec- 



30 OPERATIVE OBSTETRICS 

tion is not at present practised extensively in private houses and 
should be reserved for hospitals. 

All labors should be so conducted that the patient is in proper 
condition for anesthesia during delivery. During labor the patient 
should take only broth or gruel, or raw egg made palatable. Milk 
should be avoided, as the excitement and pain of labor delays its 
digestion and absorption. In view of the possibility of anesthesia, 
the patient's general strength should be sustained, and she should 
be brought to the active stage of labor in good condition for an 
anesthetic. 

In selecting the anesthetic for an obstetric operation, choice will 
depend upon the operation to be done and the circumstances present. 
In all cases where it is not necessary to relax the uterus to change the 
position of the child, ether should be employed. In shoulder pre- 
sentations, where the uterus is tetanically contracted and it is desired 
to relax it to permit version, chloroform should be given during ver- 
sion, followed by ether during extraction. For short manipulations, 
where it is necessary to carry the hand or instruments within the 
uterus, as in placing elastic bags, chloroform may be used well 
diluted with air. 

In the great majority of cases ether is the better anesthetic, 
being safer and giving better results. 

I have recently tried ethyl chlorid in short manipulations and 
normal labor. Its action was disappointing, although it was given 
by one accustomed to its use in general surgery. Uterine contrac- 
tions grew less under its use, and there was a greater tendency than 
usual to relaxation and hemorrhage. 

In hospital practice, and with highly nervous patients, brief 
manipulations may be done with nitrous oxid. 

The Administration of Ether. — Ether is most usually given in 
obstetric practice for forceps operations, extraction by the breech, 
embryotomy, opening of the pubes, delivery by abdominal section, 
and the repair of lacerations. None but the best quality of sul- 
phuric ether should be used. The anesthetizer should have ready 



OBSTETRIC ANESTHESIA 31 

instnnnonts for opc^iiii^i?; the inoutli, pulling- out the tongue^ giving 
hypodennic injoctions, and intravenous saline transfusion. If the 
patient is shocked or (lei)ressed, or has heart lesions, oxygen should 
also be available. Obstetric operations should be done with the 
patient across a high, narrow bed, or placed upon a table wher(^ the 
anesthetizer can work without difficulty. The low, broad bed is an 
abomination for all obstetric procedures. In commencing cither 
the anesthetizer must endeavor in cases of vaginal delivery to 
stimulate uterine contractions by the anesthetic. If ether be 
inhaled in small quantities with each uterine contraction, the 
inhibitory influence of pain is removed and uterine contrac- 
tions are usually more efficient and vigorous. As the patient's 
respiratory capacity is lessened by the enlarged womb, she 
should take ether graduall}^, avoiding irritation as much as pos- 
sible. If the operation is to be a very long one, oxygen may be 
inhaled with the ether. Care should be taken that the patient lies 
in the best possible position, so that mucus can readily be expelled, 
and the anesthetizer should keep the mouth and throat as free from 
mucus as possible. As the patient proceeds to complete anesthesia, 
in forceps deliveries and breech extractions, the operator may desire 
assistance from the anesthetizer in stimulating uterine contractions 
or pressing the child downward into the pelvis. Complete surgical 
anesthesia is usually necessary when the child passes over the pelvic 
floor. Incom.plete anesthesia at this time results in reflex struggle, 
which embarrasses the operator and favors the production of lacera- 
tions. 

As soon as the child is delivered the anesthetic should be removed, 
and the patient allowed to come into the stage of light anesthesia. 
She should be maintained in this condition during the delivery of 
the placenta, and, if possible, during the closure of lacerations. If 
necessar}', the anesthesia may become more profound if the patient 
struggles. 

A marked change in the respiration and the pulse tension of the 
patient will be observed when the uterus is empty. The anesthetizer 



32 OPERATIVE OBSTETRICS 

should be prepared for this, and, if necessary, should give stimulation 
hypodermically at this time. A skilled obstetric anesthetizer 
should assume entire charge of the patient's vital condition during 
operation, greatly to the advantage of the patient and the relief of 
the operator. At the close of an obstetric operation, if the patient 
is in bad condition, the anesthetizer should give such stimulation as 
is necessary, including intravenous saline transfusion. 

Experience has shown that during obstetric operations patients 
bear well strychnin and digitahs hypodermically. If bronchial 
catarrh is profuse, atropin may be added. As soon as the uterus is 
empty, ergot should be given hypodermically. Intravenous saline 
transfusion in moderate quantity is also useful. If the blood-pressure 
be very low, adrenalin (1 : 1000) may be added to the saline fluid in- 
jected into the vein. 

Anesthesia by Chloroform. — In giving chloroform to obstetric 
patients none but the best chloroform should be selected, and this 
should be given freely diluted with air. 

Where bronchial comphcations are present, chloroform diluted 
with oxygen is of especial value. For brief manipulations, which 
require partial dilation of the uterus, chloroform is valuable, while 
it is especially useful in cases of threatened uterine rupture and 
shoulder presentations where version must be done. 

While comphcated masks are useful in the hands of those familiar 
with them, in general, chloroform is most safely given upon a hand- 
kerchief or piece of gauze, held from 1 to 2 inches from the patient's 
nostrils. 

Great care should be taken in giving chloroform that the patient 
is completely relaxed before version or dilation of the uterus be 
attempted. The large number of deaths under chloroform anesthesia 
have occurred under partial anesthesia only. The depressing effect of 
the drug is present under such conditions, while the reflexes are not 
abolished. As a result, the patient is shocked by the painful reflex, 
and the heart, depressed by the chloroform, stops. The safe use of 



OBSTETRIC ANESTHESIA 33 

chloroform requires that thc^ patient be entirely unconscious, breath- 
ing deep and regularly, with good })ul^^e and good color. 

Where it is desired to adniinist(^r oxygen gas with chloroform, 
an Allis inhaler or chloroform mask may be used, the tube from 
the oxygen tank being carried into the inhaler or beneath the mask. 
During the administration of chloroform the anesthetizer must watch 
the patient most closely, and, in the event of unfavorable symptoms, 
must stop the anesthetic at once, give strychnin and digitalis hypo- 
dermically, with the free administration of oxygen. As chloroform 
tends to relax the uterus, the anesthetizer must also watch for hem- 
orrhage. As chloroform is rapid in its action, its administration must 
not be begun until the operator is ready to proceed, and it should be 
stopped as soon as possible. 

Recovery from Obstetric Anesthesia. — After an obstetric opera- 
tion, care should be taken that a patient makes a satisfactory recovery 
from the anesthetic. If she vomits, the mouth should be cleaned, 
and if vomiting is persistent, the stomach should be washed out. 
As vomiting often accompanies a relaxed condition, favoring hemor- 
rhage, especial care should be taken to see that the uterus is well 
contracted. Tonic doses of strychnin hypodermically are most use- 
ful during the recovery from anesthesia. Food and water should 
be withheld until the patient is without nausea. If fluid is required 
it should be given by rectal injection. 

Anesthesia by Lumbar Injection. — It was hoped that a great ad- 
vance in obstetric anesthesia had been made w^hen lumbar injection 
of preparations of cocain, morphin, and belladonna was introduced. 
This method has been sufficiently tried at the present time to enable 
us to form a fair estimate of its value. It has been most exten- 
sively practised in Germany, where Hocheisen quotes 2000 cases, with 
25 deaths; Roith, 4000 cases, with 18 deaths.^ Gauss ^ had good re- 
sults in 500 cases. In Hocheisen 's cases the method was ineffectual 
in 18 per cent., but this did not seem to depend upon the dose used. 

1 Monatsschrift f. Geb. u. Gyn., Band 59, Heft 1. 

2 Zentralblatt f . Gyn., 1907, No. 2. 



34 OPERATIVE OBSTETRICS 

In 65 per cent, the patients fell into a light sleep after anesthesia 
terminated. In 70 per cent, there were unpleasant after-effects^ 
such as redness of the face and throat and thirst. In some cases the 
distress was so acute that it was thought unsafe to leave the patient 
without the care of a physician. In 24 per cent, the pressure of the 
abdominal muscles was distinctly lessened, as in 25 per cent, the use 
of forceps was necessary. The length of labor was increased, post- 
partum hemorrhage more frequent, 1 fatal case being reported; the 
placenta came away more slowly than usual, and involution was 
retarded. Disturbance in the pulse was observed in 20 per cent. 
NewelP has tried scopolamin morphin by lumbar injection, and his 
results agree essentially with those stated by German observers. 
AVith skilful administration it is possible to produce local anesthesia 
in a considerable number of cases, but the method is somewhat un- 
certain and requires constant and intelligent supervision. Gauss ,^ 
after a large experience with lumbar injection, advises injection into 
the subarachnoidian space with the patient in the sitting posture, 
and with the patient remaining in this posture four or five minutes 
after the injection. After this she may lie clown, preferably with the 
pelvis raised. Stovain, an average dose of 0.07, in weak individuals 
reduced to 0.05, is administered. This dose should not be exceeded. 
Where transient and partial anesthesia is necessary, a smaller dose 
may be employed. The specific gravity of the injected fluid is im- 
portant, and Gauss has determined this b}^ observations upon the 
specific gravity of the cerebrospinal fluid. The lower the specific 
gravity of the fluid the more certain the efficiency of its anesthetic 
effect. In most cases 4 per cent, solution is most available. The 
choice between tropacocain, novocain, or stovain is not of especial 
importance. Gauss had good results in 1500 cases with stovain, and 
believes that success depends more upon the method of administra- 
tion than the particular preparation employed. 

1 Trans. Amer. Gyn. Soc, vol. 31, 1906. 

2 Zentralblatt f . Gyn., No. 31, 1909. 



OBSTETRIC anesthp:sia 35 

Frcuntl ^ hajs luul good iv^sults with cucain-aclrciialiii; liLs solution 
is as follows : 

J^. Eucain, 0.1; 

Natr. chlorat., 0.00; 

Solut. adrenalin., 10/00, O.S; 

Aq. dcstillat., ad. 10.0.— M. 

Of this preparation he gives the contents of two hypodermic syringes 
for operations of a half-hour or more. Fisch " employs novocain and 
suprarenin, and has had good results from this method. That com- 
bination most extensively employed has been scopolamin morphin. 
Gauss used scopolamin, 0.3075 with 0.01 morphin. Others have 
varied the amount of scopolamin slightly, the amount of morphin 
remaining practically the same. In general, it may be stated that 
considerable diminution of pains in parturition was observed in 6 
per cent, of patients recei\ang lumbar injections. In about 30 per 
cent, labor w^as prolonged, and in the remainder no efficient result 
follow'ed. A sufficient number of accidents by this method have been 
reported to lead to the conclusion that the method should be restricted 
to hospital practice only, w^here the patient is under constant ob- 
servation, with all appliances for resuscitation. Those who think 
best of the method would apply it to anemic, cachectic, and fat 
patients. 

The Effect of Anesthesia During Obstetric Operations Upon the 
Fetus. — Prolonged anesthesia during parturition affects the child. 
It breathes with more difficulty, is slower in reacting, and may be 
resuscitated with great difficulty. After lumbar anesthesia, abnormal 
conditions in the circulation and pupil, with abnormal respiration, 
have been observed. Under skilful anesthesia obstetric operations 
are performed with ether without detriment to the chikl, but, if anes- 
thesia were not properly conducted, considerable fetal mortality and 
morbidity would result. 

Surgical Narcosis in Women. — An extended review^ of this subject 
has been made by Roith.^ He collected 98,939 cases of inhalation nar- 

1 Zentralblatt f. Gyn., No. .31, 1909. ^ Zentralblatt f. Gyn., No. 31, 1909. 

3 Monatsschrift f. Geb. u. Gyn., 1907, Band 26, Heft 1. 



36 OPERATIVE OBSTETRICS 

cosis and 11,692 cases of local anesthesia in the practice of 783 physi- 
cians. The complication most frequently following the inhalation of 
anesthetics in obstetric operations was pneumonia, which occurred 
in 3.4 per cent., with mortality of 7.5 per cent. Under local anes- 
thesia the mortality from pneumonia was 4.8 per cent. ; the morbidity 
12.8 per cent. 

In 87,530 anesthesias with chloroform there were 54 fatalities — 
1 in 683. In the majority of cases ether is safer than chloroform. 
A preliminary injection of | gr. of morphin one hour before operation, 
followed by ether, has given good results. In 21,000 cases of inhala- 
tion anesthesia, unfavorable symptoms were seen in these more fre- 
quently with chloroform and its mixtures than with others. Com- 
plications are more frequent in winter than in summer. The tendency 
of ether to excite bronchitis is seen in the fact that, after the use of 
ether, bronchitis occurs once in 400 cases; after the use of chloroform, 
once in 3300. So far as safety is concerned, ethyl chlorid gave but 
1 death only in 8500 anesthesias. In all, 22 deaths from ethjd chlorid 
have been reported, giving a mortalit}^ of 1 in 16,000; 5000 chloro- 
form inhalations are reported with but 1 death, and 9289 ether 
inhalations without a death. Mixtures of anesthetics are more dan- 
gerous than one pure substance. 

It is of especial interest to obstetricians to note the results seen 
after prolonged anesthesia in the production of acidosis and aceto- 
nemia. This is especially apt to occur after the use of chloroform, and 
develops in five days or more after the operation. Degeneration in 
the cells of the kidneys, liver, and connective tissues, in the heart 
muscle, and in the epithelia of the body are observed. The heart 
and liver are affected sooner than the kidnej^s. Chloroform, ethyl 
bromid , and ethyl chlorid are more apt to produce these changes 
than is ether. On the other hand, under prolonged etherization small 
areas of pneumonia are observed, with accumulation of mucus, extrav- 
asation of blood corpuscles, and cell infiltration in the surrounding 
tissues. Under all circumstances, anesthesia should be as brief as 
possible, and should not be repeated in from three to six days, if it 



OBSTETRIC ANESTHESIA 37 

can be avoided. P'atty degeneration in the heart, kidneys, and liver 
contraindicates anesthesia, ^^'here acetonemia develops after opera- 
tion, the symptoms are vomiting, coma, and very active delirium. 
Every effort should be made to introduce alkalies into the body as 
extensively as possible, but results of treatment are seldom successful. 
Strychnin and caffein may be given hypodermically. In general, acci- 
dents following anesthesia may be in some degree prevented by dis- 
infecting the mo th and pharMix with an antiseptic solution before 
anesthesia. A tonic dose of stryclinin or digitalis, or strychnin and 
digitalis together, may be given hypodermically before anesthesia. 
In hard cases small doses of morpliin are sometimes useful to allay 
the patient's apprehensive condition. 

In heart failiu'e during the operation, massage of the heart tlirough 
the abdominal wound, if laparotomy is the operation, by manipulating 
the diaphragm, has given some success. The application of electricity 
and the injection of adrenalin should be tried. The injection of 
camphor or atropin, or str^X'hnin and digitalis should be employed, 
and. rarely, tracheotomy and inflation of the lungs. 

Anesthesia is especially dangerous in highly toxic patients and 
those depleted by hemon-hage. In operating during eclampsia the 
tendency to acetonemia should be remembered: such patients should 
be given salt solution as freely as the circulation will permit. In 
septic cases, -^ith a tendency to hemorrhage, adrenalin is of use until 
the operation can be completed, when uterine bleeding may be con- 
trolled by packing. 

A bibliogi'aphy of the recent literature, with especial reference to 
spinal anesthesia, is appended. 

Bibliography of Obstetric Anesthesia 

Avarrfy: G\ti. Rimdschau. p. 338, 1909. 
Bass: Mimchener med. Wochenschrift. Xo. 11. 1907. 
Bertoni: La Ginecologia, vol. 4. p. 609. 1907. 
Birchmore: Medical Record, January' 17, 1907. 
Buist: British Medical Journal. September 19, 190S. 
Butler: American Journal of Obstetrics, August, 1907. 



38 OPERATIVE OBSTETRICS 

Croom. J. Halliday: Journ. of Obstetrics and Gynecology of the British 

Empire, July, 1909. 
Dean: British Medical Journal, May 12, 1906. 
Fehling: Zentralblatt f. Gynakologie, p. S93, 1909. 
Fisch: Zentralblatt f. Gynakologie, Xo. 31, 1909. 
Freund: Zentralblatt f. Gynakologie, Xo. -IS, 190-1, and Xo. 31, 1909. 
Gauss: Miinchener med. Wochenschi'ift, X'o. 4, p. 157, 1907; Zentral- 
blatt f. Gynakologie, X^o. 2, p. 33, 1907, and X^o. 31, 1909. 
Gminder: Beitrage f. Geburtshiilfe luid Gynakologie, Band 12, p. 299. 

1907. 
Halpenny and Vrooman: American Journal of Obstetrics, Oct., 1909. 
Hocheisen: Monatsschrift f. Gebmishiilfe und Gynakologie, Band 25, 

Heft 1, 1907; Miinchener med. Wochenschrift, Xo. 11, 1907. 
Holzbach: Miinchener med. Wochenschrift, Xo. 25, 1907. 
Kalb: Monats. f. Geburtshiilfe u. Gynakologie, Bd. 30, p. 607, 1909. 
lOeinertz: Zentralblatt f. Gynakologie, p. 13S7, 1907. 
Kroenig: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 25, 

p. 564, 1907; also Band 30, p. 518, 1909.^ 
Lea : Journal of Obstetrics of the British Empire, Januar}', 1902. 
Mayer: Zentralblatt f. Gynakologie, p. 689, 1907. 

McKerron: Journal of Obstetrics of the British Empire, December, 1908. 
Miiller: Monatsschrift f. Geburtshiilfe und Gynakologie. Band 21, Heft 

2, 1905. 
X^ewell: Surger}^, Gynecology, and Obstetrics, Jul}^, 1906, August, 1907. 
Preller: Miinchener med. Wochensclmft, Xo. 4, p. 161. 1907. 
Risch: Zentralblatt f. Gynakologie. Xo. 30, 1909. 
Roith: Monatsschrift f. Geburtshiilfe und Gynakologie. Band 26, Heft 1, 

1907. 
Sellheim: Zentralblatt f. Gynakologie, Xo. 26, 1905. 
Steffen: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 26, p. 

589, 1907; Archiv f. Gynakologie, Bancl 81, p. 451, 1907. 
Stockel: Monats. f. Geburtshiilfe u. Gynakologie, Bd. 29, p. 378, 1909. 
Stoeckel: Zentralblatt f. Gynakologie, Xo. 1, 1909. 
Stolz: Archiv f. Gynakologie, Bancl 73, Heft 3, 1904. 
Thomson: Zentralblatt f. Gynakologie, Xo. 31, 1909. 
Tobiaszek: Zentralblatt f. Gynakologie, p. 1665, 1909. 
von Bardeleben: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 59, 

p. 144, 1907. 
von Franque: Monats. f. Geburts. u. Gynakol., Bd. 30. p. 615. 1909. 
Wernitz: Zentralblatt f. Gjmakologie, Xo. 31, 1909. 
Westermark: Archiv f. Gynakologie, Bd. 89. Hft. 1, 1909. 
Zulaf : Zentralblatt f. Gynakologie, Xo. 20, 1902. 



The Technic of Obstetric Surgery 
obstetric operations in hospitals 

The Operating-room. — ^laternity hospitals require several operat- 
ing-rooms, which should be kept ready for use. Emergency la})or 
cases sent to hospitals are always suspicious as regards their aseptic 
condition, and many have already been infected. It would be obvi- 
ously unfair to operate upon them in a room which might imme- 
diately after be needed for a case which had been in the ward 
sufficiently long to be known to be uninfected. If possible, each 
operating-room should have a separate sterilizing outfit and a sepa- 
rate water supply, so that, if necessary, several operations may pro- 
ceed simultaneously, as confinements occur often in gTOups. These 
rooms should be of convenient size, properly Ughted and heated, 
with seats or standing room for students, in teaching hospitals. In 
such operating-rooms the space utilized for operations may be shut 
off from spectators by a heavy glass screen, permitting vision, but 
preventing, as far as possible, contamination. 

Operating Tables. — For operations requiring vaginal delivery a 
high, firm table should be selected, to wliich may be fitted, if desired, 
supporting stirrups for the feet and legs. Their use will economize 
the work of nurses, and is usually convenient for the operator. Such 
tables should stand firmly, and should be sufficiently high to enable 
the patient to be put in Walcher's position. A high table will also 
be found convenient in permitting the operator to stand during the 
performance of forceps extraction, version, and craniotomy, For 
abdominal section a suitable table is needed with an attachment for 
the complete Trendelenburg position. This may be necessary in 
ruptured ectopic gestation, in removing tumors complicating preg- 
nancy and situated at the bottom of the pehis, and in other con- 
ditions requiring exploration of the deeper tissues in the pelvic 

39 



40 OPEEATIVE OBSTETRICS 

cavity. The Trendelenburg position will also be useful in some 
cases of severe shock and hemorrhage, as in rupture of the uterus. 

Sterilizing Apparatus. — The autoclave or other sterilizing apparatus 
may be employed, but it should be so arranged that it can be used at 
a moment's notice at any time, day or night. The source of heat 
must be under the control of the nurses in charge of the operating- 
room, and must not be derived from a central plant. As obstetric 
operations must often be done at night, there must be no delay in 
securing the necessary heat. The sterilizing apparatus should have 
sufficient capacity to sterilize sheets and blankets as well as dress- 
ings and instruments. Whenever possible, sterilization should be 
by steam, followed by dry sterilization as well. 

The Sterilization of Obstetric Instruments. — Many of these are 
larger than other instruments used in surgery, and will require ster- 
ilizing trays or pans of suitable size. Obstetric instruments may be 
boiled in 1 per cent, lysol without doing other injury than dulling 
the cutting edges of the knives. Some operators prefer to have the 
forceps and other obstetric instruments remain in a sterilizing pan 
covered with antiseptic fluid. Lysol is convenient for this purpose, 
as it renders the forceps sufficiently slippery for introduction without 
other lubricant. Others prefer to use instruments which have been 
dried and then laid upon a table covered by sterile gauze or linen. 
Some obstetric instruments are composed of a number of parts, such 
as the obstetric trephine and basiotribe, and these should be taken 
apart, thoroughly scrubbed with soap and soda and hot water after 
use, and then boiled in lysol and dried. Before operation they should 
be thoroughly inspected, and if not clean, the cleaning should be 
repeated and the instruments boiled and thoroughly sterilized before 
the parts are put together. 

Bougies for the introduction of labor cannot be sterilized by heat. 
They must be thoroughl}^ washed with soap and water, rinsed in 
sterile water, and soaked in bichlorid solution (1 : 1000). Dilating 
bags may be boiled, although this process injures the elasticity of the 
rubber and causes the bag to deteriorate. They should be filled, 



OBSTETRIC OPERATIONS IN HOSPITALS 41 

at least partially, with fiuicl bt^fore boiling, and should hv thoroughly 
tested and inspected to see that no leak is present. After sterihza- 
tion they should be kept in an antiseptic solution until used. Obstet- 
ric instruments require sterilization for at least half an hour, and, 
when time permits, the instruments and apj^liances to be used at 
an obstetric operation can be sterilized for one hour with advantage. 
Rubber gloves should be sterilized by boiling, then dried, the fingers 
packed with sterile gauze, and the gloves powdered with sterile talc 
powder and wrapped in sterile gauze. Many operators prefer to put 
them on in the dry condition. Others prefer to fill them with an 
antiseptic solution. 

Antiseptic Fluids. — Bichlorid of mercury in solution (1 : 2000) is 
employed by many for cleansing the external genital organs. Where 
vaginal douching is required, bichlorid solution should not be stronger 
than 1 : 4000. For preparing the vagina for vaginal operations 
in cases akeady infected sterile soapsuds may be used as a pre- 
liminary injection, and the vaginal mucous membrane may be 
thoroughly washed with sterile soapsuds and gauze. A copious 
douche with sterile boiled water should then be given, followed 
by bichlorid solution (1 : 4000) or lysol (1 per cent.). Carbolic acid in 
2 per cent, solution is used by some for the sterilization of instru- 
ments, but its use has been largely superseded by lysol. Where 
uterine irrigation is required, sterile salt solution or lysol (1 per 
cent.) is usually employed. 

In maintaining asepsis about the nipples a saturated solution of 
boric acid is usually employed, and also in the aseptic care of the 
infant. In the prophylaxis of ophthalmia, nitrate of silver, 10 gi\ 
to the ounce, or 20 per cent, solution of arg}Tol, are usually required. 
Among English obstetricians a port-wine-colored solution of tincture 
of iodin in sterile boiled water is sometimes used for irrigating the 
uterus. For intra-uterine injections in septic cases a 1 per cent, for- 
malin solution has been employed. 

Obstetric Instruments. — Such should be of the best quality, 
thoroughly nickel-plated, and free from dirt and rust. The instru- 



42 OPEEATIVE OBSTETRICS 

ments should be carefully cleansed after each operation, boiled in 
lysol solution (1 per cent.'), and dried. This should be repeated 
before their use. The rubber handles formerly used in the forceps 
have been discarded by most manufacturers, and metal handles 
substituted. If the rubber handle is of first-rate quality, it may 
be utilized indefinitely without injury: but if it be of the cheaper 
sort, repeated sterilization will injure the rubber. 

Such are the emergencies of obstetric practice that, in preparing 
for vaginal delivery, it may be necessary to have in readiness not only 
the forceps, but instruments for embryotomy as well. There should 
be a number of good hypodermic syringes in good order, an electric 
battery for resuscitation, and instruments suitable for intravenous 
transfusion. An independent source of light is most important in 
obstetric operations, and a portal^le electric drop-light is especially 
useful. Such may be focused upon the perineum and peMc floor 
or into the abdominal cavity. 

The Asepsis of the Operator. — Obstetricians, whether in hospital 
or private work, should avoid sources of septic contamination. They 
should not make autopsies or study pathologic specimens, and should 
avoid, as far as possible, contagious diseases. After operating 
upon a septic case a thorough bath and an antiseptic bath should 
be taken, with thorough shampooing of the head and a complete 
change of clothing. In operating, street clothing should be discarded 
and sterile linen or duck worn in its place. If necessary, a clean 
rubber apron may be worn beneath a sterile gown. 

Before operating, the operator requires suitable clothing — a sterile 
gown whose sleeves reach easily to the wrists, an antiseptic covering 
for the head and hair, and, for all cases of section, a face mask as well. 
Gloves should be worn, and the go^\Ti sleeves folded snugly at the 
wrists and covered by the wrists of the gloves. 

In cleansing the hands, the operator may select any of the methods 
which have given practical satisfaction. That most usually em- 
ployed consists in trimming the nails smoothly, cleaning them thor- 
oughly with an orange-wood stick, and scrubbing the hands, wrists, 



OBSTETRIC OPERATIONS IN HOSPITALS 43 

and forearms, iiu'ludin^- the lo\v(>r 1)0111011 of the anus, with green soap, 
or tincture of green soap and hot water, for at k^ast fift(^en minutes; 
after this, thorough scrubl)ing in liot sterile water. This 
should be followed by a thorough cleansing with bichlorid solu- 
tion (1 :2000). A thorough application of 95 per cent, alcohol, and 
drying with a sterile towel, should precede the putting on of the 
gown and gloves. The hands should be heavily powdered with sterile 
talc to prevent, if possible, undue perspiration. 

Some prefer the use of permanganate solution and oxalic acid 
in cleansing the hands, and others prefer the hypochlorid of lime 
paste, followed by sterile water and bichlorid. 

Ob\dously, the operator's success in asepsis will depend not only 
upon his preparations, but upon his avoidance of non-sterile articles 
during operation. No matter what emergency may arise, he must 
form such habits that he will not be led to violate aseptic precautions. 

Should an operator become infected, he cannot safely do obstetric 
operations until the focus of infection has entirely healed, and he has 
had sufficient time to disinfect as carefully as possible. The operator 
having a septic focus of any sort in the body is a source of danger to 
his patients. 

The Preparation of the Patient. — In obstetric hospitals patients 
may be prepared for abdominal section by any of the methods em- 
ployed in good surgical hospitals. Each operator should select cer- 
tain things which he deems essential, and the obstetrician should 
have printed directions for preparation, and the nurses and assist- 
ants should follow them strictly. From the nature of the case there 
is often not so much time to prepare an obstetric patient for operation 
as is available for other surgical cases. Hence, the obstetric prepa- 
ration should be especially thorough and careful. In scrubbing 
the abdominal surface and in cleansing the external genital organs 
gTeen soap in solution is especially useful. The parts should be 
shaved, and after the use of the soap they should be thoroughly ir- 
rigated with hot sterile water. Bichlorid solution (1 : 2000) may 
then be employed, followed again by sterile water. A moist bichlorid 



44 OPERATIVE OBSTETRICS 

dressing (1 : 2000) may be placed upon the abdominal surface or 
over the vulva until the moment of operation. 

In preparing suspected cases for vaginal delivery we have found 
useful a mixture of green soap in paste, lysol, and hot sterile water. 
If preferred, the tincture of green soap and lysol may be used. Be- 
fore vaginal operations the region about the anus and that of the 
urethra should receive especial attention, and, if there be time, the 
rectum may be thoroughly irrigated with salt solution. The bladder 
should be catheterized just before the operation, preferably when 
the patient is anesthetized. It is well to prepare an arm for intra- 
venous saline transfusion in cases where the operation may be pro- 
longed, and where the patient is not in good condition. 

Preparation for the Care of the Infant in Hospitals. — After difficult 
obstetric operations, infants are frequently born partially asphyxi- 
ated and sometimes suffering from birth pressure. Such require 
not only prompt attention, but especial care during the next few days. 
Portable incubators should be in readiness, so that such a child may 
be kept thoroughly warm from the moment of birth and transferred 
in an incubator to the nursery of the hospital. 

In the event of wounds or injuries to the fetus, the usual appliances 
for aseptic cleansing and dressings will be needed. 

Suture and Ligature Material. — In an obstetric hospital a com- 
plete assortment of silk, catgut, and silkworm-gut should be in readi- 
ness. If possible, the silk should be freshly boiled before each opera- 
tion. Catgut should be prepared to last in the tissues at least two 
weeks, and any reliable brand fulfilling this indication may be 
selected. It is often safer to have the hospital nursing staff prepare 
the catgut than to trust to manufactured varieties. Iodized catgut 
as prepared by the nurses of the Jefferson Hospital, has given, in our 
hands, excellent results. Nos. 1 and 2 are most usually employed. 
Silkworm-gut should be of the best quality and the largest obtain- 
able. 

In closing lacerations of the perineum the smaller and thin silk- 
worm-giit cuts the tissues and is not strong enough. 



TO COXDITT OBSTETRIC OPERATIONS IN PRIVATE HOUSES 45 

The Cleaning and Fumigation of Operating Rooms. — Rooms used 
for obstetric operations should ha^'e walls antl floors capable of being 
thoroughly washed and fumigated frequently. If metal or tile is not 
available in construction, and ordinary materials be used, the em- 
ployment of enamel paint, frequently applied, will enable those in 
charge to wash and fumigate the walls as often as necessary. The 
w-ashing should be done with a strongly alkaline soap, followed 
by rinsing with boiled water, and the fumigating may be advan- 
tageously performed by vapor of formaldehyd. All articles used in 
such an operating-room which cannot be boiled should be included 
in the fumigation. The fact that formaldehyd does not injure 
metals and fabrics has caused it to supersede sulphur as a fumi- 
gating agent. 

Some prefer, in addition to cleansing with soap and water, to 
have the walls and floors thoroughly washed with bichlorid solu- 
tion (1 : 1000). This injures the metal finishing and, if used in excess, 
may result in irritation to those w^ho use the room. Operating- 
rooms should have a bountiful supply of sunlight, and should be 
kept well aired and illuminated by the sun when not in use. The 
source of heat should be such that dust will not be brought into 
the room by flues or ventilators. It should be possible to raise the 
temperature of such operating-rooms to 75° or 80° F. w^henever 
occasion demands. 

TO CONDUCT OBSTETRIC OPERATIONS IN PRIVATE HOUSES 

With the appliances of a well-found hospital obstetric opera- 
tions may readily be conducted under the same precautions which 
have made general surgery so successful, but many obstetric 
patients must be delivered in their homes, and here the problem 
of maintaining and practising antisepsis becomes more difficult. 

The Confinement Room. — AYhenever possible, a room should be 
selected for confinement into which no drain opens, which has an 
open fireplace, and a free exposure to sunlight and air. 

No room in which an infectious or contagious disease has oc- 



46 OPERATIVE OBSTETRICS 

curred should be selected for confinement. Curtains, carpets, and 
upholstered furniture should be removed if it can possibly be done. 
The floors should be thoroughly scrubbed with a strong alkaline soap, 
and if rugs are desired they should be thoroughly cleansed or fumi- 
gated before use. Whenever possible the source of heat should be an 
open fire or hot-water heating, and furnace flues should not com- 
municate with the room. It should be on the same floor with the 
bathroom or water supply and toilet-room, and, if possible, in a. 
quiet part of the house. 

The Selection of Beds and Tables. — For the more serious obstetric 
operations a suitable operating table should be taken to the house^ 
and, if this is not convenient, an operating table must be improvised. 
An ordinary clean kitchen table answers the purpose well, suitably 
covered with a clean blanket and clean hnen, with the addition of a. 
rubber pad for drainage. Several other small tables, thoroughly 
cleaned, may be covered with sterile linen and used for instruments,, 
basins, pitchers, dressings, and other needed articles. 

It is sometimes difficult to obtain a suitable table, and some 
patients are greatly frightened at the idea of being placed upon a 
table for delivery. If a narrow, high, single bed can be procured, witli 
one or two firm hair mattresses, this will serve for forceps delivery, 
the delivery of the placenta, and the closure of lacerations. It should 
be raised sufficiently high for the convenience of the operator. An 
iron hospital bed, if possible, should be procured, and this may be 
raised on four cubical blocks, 8 inches in diameter, to a convenient 
height. Such a bed raised upon blocks will be found most conve- 
nient for any illness, and so may be kept in the family to advantage 
after the confinement. The mattress may be so protected with 
rubber sheeting, with the help of a rubber pad, that it 'will not be- 
come soiled, and instrumental delivery can be accomplished in many 
cases in a satisfactory manner. For the use of Walcher's position, 
the performance of version, opening the pelvis, craniotomy, or open- 
ing the abdomen a table will be found necessary. 

Where it is impossible to remove old carpet from the floor, the- 



TO CONDUCT OBSTETRIC OrKHATIONS IN PRIVATE HOUSES 47 

nurse may spread over the carpet, beneath and about the patient's bed^ 
old linen which has been boiled, dipped in bichlorid solution, and dried. 
This will prevent the dust from the carpet infecting the patient. 

Water Supply. — The water supply in many private houses may 
become a source of infection, and corresponding precautions must be 
taken. Water used during confinement, and especially during ob- 
stetric operations, should be thoroughly boiled. It is well, if pos- 
sible, to use filtered water, and by some distilled water is preferred. 
A copious supply of hot water must be available in preparing for 
operations, and during and after the operation itself. 

Appliances for Operation in Private Houses. — If possible, the 
obstetric nurse should procure an abundant supply of agateware 
basins and pitchers, or cheap china basins and pitchers, before the 
confinement. These can be scrubbed and cleaned thoroughly, and, 
if possible, boiled, without fear of great loss should breakage occur. 
Agateware utensils are useful in a household at any time. As irri- 
gation may be required, a new fountain syringe should be procured, 
and this should be boiled before it is used. 

Methods of Sterilization in Private Houses. — An Arnold sterilizer 
will often be found useful, and in communities where the operator 
must improvise hospital facihties himself he may find it more satis- 
factory to use his own than to trust to the domestic utensils of the 
patient. If a sterilizer cannot be procured, a thoroughly clean wash- 
boiler may be used, and linen and other needed suppUes prepared in 
that. A new, clean fish kettle is also a convenient utensil. 

The obstetrician, however, must have his own independent ap- 
paratus for sterilizing his instruments, gloves, and appliances. Some 
prefer to have the sterilizing done at the obstetrician's office, the 
various instruments wrapped in sterile linen and tagged, and thus 
carried in a sterile and dry condition. 

In the writer's experience it has seemed best to steriUze instru- 
ments and appliances just preceding their use, having them kept in a 
thoroughly clean condition when not in use. We employ to our satis- 
faction a double copper nickel-plated box, the smaller fitting into the 



48 OPERATIVE OBSTETRICS 

larger half, which serves as a cover. This is sufficientl}^ large to con- 
tain many obstetric instruments, and the instruments may be carried 
in this sterilizer with gloves and other supplies. Two supports and 
two alcohol lamps furnish a convenient and efficient source of heat. 
To prevent danger of fire from the use of alcohol, we are accustomed 
to place the sterilizer on the bottom of an empty bath-tub, boiling 
its contents in 1 per cent, lysol for at least half an hour. The ster- 
ilizer need not be opened until the instruments are required; the 
larger half inverted gives an additional sterile tray for the division of 
the instruments into convenient groups. Silk and silkworm-gut may 
be conveniently boiled with the instruments, and catgut in tubes 
may be reheated when the instruments are sterilized. 

The obstetrician will also carry with him a rubber pad, an outfit 
of sterile operating clothing, a rubber apron, gauze for packing the 
uterus, a sufficient supply of antiseptics to serve in any emergency, 
hypodermic syringes, and such drugs as are necessary for the relief 
of pain and for stimulation in all surgical cases. Such supplies may 
be conveniently packed in a suitable case or bag. For out-of-town 
practice, if a number of these outfits are kept in readiness, one may 
be sent in advance to the house of the patient, greatly to the con- 
venience of the operator. 

Surgical Dressings. — Where strict economy need not be practised, 
aseptic bichlorid, iodoform, or borated gauze or cotton can be ob- 
tained in sealed packages. If the patient must economize, the nurse 
who is in charge of the case should haAT in readiness a supply of 
sterile vaginal dressings, abdominal binders, breast-binders, sheets, 
towels, and sterile linen for the patient's use. 

It is well to select plain underclothing, and that which can be 
torn, if necessary, without occasioning much loss. The obstetrician 
should furnish the patient in advance a list of such antiseptics, stimu- 
lants, and other articles which should be kept in the house, and the 
nurse should see that all is in readiness before the time of confinement. 

Cheap but efficient vaginal dressings can be prepared by select- 
ing the cheaper grades of cheesecloth, boiling them in soda and water 



ASSISTANTS P^OR OBSTETRIC OPERATIOXS 49 

to rendor thoiu ^oh, isoakiiig thrin in hichlorid solution and drying, 
and including in the dressing tlu' chcaix^r grade of cotton batting, 
the whole being sterilized by baking. These may be wrapped in 
sterile linen or a sterile towel and properly labeled. The invariable 
rule after obstetric operations must be that all soiled dressings 
are to be burned as soon as possible after their removal. 

For maintaining asepsis in the infant, very soft old linen steril- 
ized by boiling is especially useful. For ligating the umbilical cord, 
the operator may employ surgeons' silk boiled with the instruments. 
As the birth may possibly be precipitated before his arrival, the nurse 
should also prepare sterile ligature material. 

Many patients are comforted to have in readiness a supply of 
ether. The most request its administration for spontaneous birth 
and for minor surgical procedures. The operator or his assistant 
should have a sufficient supply of anesthetics for each case. 

ASSISTANTS FOR OBSTETRIC OPERATIONS 

The time is fortunately past when the obstetrician is expected to 
anesthetize the patient himself, give the anesthetic to a friend or 
relative, and then proceed to perform the operation. The obstetric 
anesthetizer should not only administer the anesthetic, but he should 
have experience in treating parturition and be competent to stimu- 
late the uterus to contraction during delivery, and to watch its con- 
dition after it has been emptied. The administration of anesthetics 
and assisting in obstetric operations cannot be undertaken properly 
by surgical anesthetizers or by unskilled physicians. Complications 
frequently arise at confinement where skill and experience are neces- 
sary for mother or child, or for both, at the same time. Hence the 
service of two obstetricians is demanded for these cases. 

In addition to a competent obstetric anesthetizer, we have found 
it advantageous to have a special obstetric nurse at confinement 
cases, who has charge of the instruments and supervises the conduct 
of the operation. In every case recjuinng interference there is abun- 
dant work for two nurses. 

4 



50 OPERATIVE OBSTETRICS 

No surgeon would think of undertaking operations as difficult as 
those of obstetrics without suitable appUances and assistants, and it 
is unjust to both patient and obstetrician that similar precautions 
should not be taken in difficult delivery. 

After difficult dehvery, if the mother be exhausted, especial care 
must be taken in her nursing during the first few days of the puerperal 
period. The services of two nurses will be required, as after any other 
critical surgical procedure. 

Obstetric Nursing. — "While most training schools give instruction 
in obstetric nursing, yet many do not become proficient in this 
branch, and are not competent for operative work in obstetrics. 
Competent obstetric nurses must thoroughly understand the sigTis 
and symptoms of exhaustion, hemorrhage, and beginning infection. 
They must be competent to conduct a rapid spontaneous deliveiy 
in an emergency, and must be taught how to employ Crede's 
method of placental expression should this be necessary. They 
must be competent to treat postpartum hemorrhage, excepting 
tamponing the uterus. They should also understand the essential 
treatment of asphyxia in the newborn and the simple methods of 
checking hemorrhage from the umbiHcus. 

The signs and symptoms of threatened eclampsia should be im- 
pressed upon their minds. The obstetric nurse must have the same 
conscientious habits of cleanliness and accuracy which are impera- 
tively recjuired in nurses doing general surgical work. 

BlBLI0C4RAPHY 

Endelmann: Gyn. Rundschau, p. 910, 1909. 

Gonner: Correspondenzblatt f. Schweizer arzt, Bd. 39. p. 13. 1909. 

Hannes: Zeitsch. f. Geburtsh. u. GynakoL, Bd. 65, Heft 1, 1909. 

Meissner: Zentralblatt. f. Gynakologie. p. 1520, 1909. 

Neu: Deutsche m. Wochenschrift, Xo. 10, 1909. 

Reynolds: Boston Medical Journal, June 24, 1908. 

Schauta: Weiner m. Wochenschrift, Xo. 45, 1908. 

Tsui: Archiv. f. Gynakologie, Bd. 89, 1909. 

von Franque: Wiener k. Wochenschrift, Xo. 35, 1910. 



PART I 



THE SURGERY OF PREGNANCY 



UTERINE DISPLACEMENTS 
The Cause of Uterine Displacements in the Pregnant Patient. — 

Uterine displacements are a recognized cause for threatening the in- 
terruption of gestation, may indirectly cause septic infection, and 
may seriously interfere with the comfort and general health of the 
patient. 

Anteflexions. — A sharply anteflexed pregnant womb is seen most 
frequently in those patients ill-developed, assimilating badly, with 
faulty ehmination, and with pernicious nausea and vomiting. Pelvic 
tenesmus is often present. These patients usually come to the inter- 
ruption of pregnancy because of toxemia. Dilation and cureting, 
with gauze packing, corrects the position of the uterus and usually 
relieves the symptoms. Anterior dislocations of the pregnant ante- 
flexed uterus, less pronounced in character, may occasion disturb- 
ance of the bladder through pressure and require treatment. They 
may be corrected by removing abdominal pressure with clothing, 
causing the patient to empty the bladder at frequent and regular 
intervals, and the assumption of the knee-chest posture. Tampons 
of carded wool boiled in lysol are often useful. 

Retroversion and Retroflexion of the Pregnant Womb. — This 
condition is important because of the danger of incarceration of the 
pregnant womb, followed by the death of the ovum and the develop- 
ment of infection. 

As soon as the diagnosis of retroflexion or retroversion in preg- 
nancy is made, the patient should suspend the clothing entirely from 

51 



52 OPERATIVE OBSTETRICS 

the shoulders without waist constriction. The bladder and the 
bowels should be emptied regularly, the patient should be placed in 
the knee-chest posture, and a cautious effort made to carry the 
fundus to one side of the promontory of the sacrum and above the 
pelvic brim. Violence should be avoided and the operator should 
cease his efforts if the patient complains of pain. If such effort be 
unsuccessful, a tampon of carded w^ool of moderate size and making 
but moderate pressure should be inserted, while the patient is in the 
knee-chest posture, making gentle pressure upon the fundus. This 
should be renewed in forty-eight hours. The patient may take mod- 
erate exercise, but report at once pain in the back and abdomen, and 
upon such symptoms she should go to bed and send for the physician. 

If the womb does not right itself with these simple measures at 
the end of the second or the beginning of the third month, two courses 
of action are open for the obstetrician: 

The patient may keep in bed, lying upon the sides or abdomen, 
the bladder emptied at frequent intervals, and the bowels moving 
regularly. More than two-thirds of such cases will right themselves 
without further interference. The knee-chest posture is always an 
efficient aid. 

If the patient cannot give the time to this, she should be anes- 
thetized, the bladder emptied by catheter, the rectum having pre- 
viously been emptied by injection, and the obstetrician attempt to 
replace the womb. This he may do by making pressure with two 
fingers upon the fundus, carrying it to one or the other side of the 
promontory of the sacrum (Fig. 3). In some cases this is done more 
easily if the patient while anesthetized is turned upon her side, the 
tenaculum forceps introduced into the cervix, and the cervix drawn 
gently downward and backw^ard, while pressure is made upward as 
indicated. This will succeed where adhesions have not developed. 
After the womb is replaced, the vagina should be tamponed mod- 
erately with carded wool boiled in lysol, the cervix carried backward 
and the uterus upward, to prevent a return of the retroflexion. 

If such manipulation fails, the operator has his choice of two 



UTERINE DISPLACEMENTS 



53 



methods: One consists in keeping the patic^nt in bed, placing her in 
the knee-chest posture, distending the posterior vaginal wall and pelvic 
floor with Sims' speculum and introducing vstrips of surgeon's lint, 
sterilized and soaked in sterile glycerin, into the posterior vaginal 
vault against the fundus. Moderate pressure should be exercised 
and this packing should be renewed in thirty-six or forty-eight hours. 




Fig. 3. — Replacing retro verted gravid womb. Patient in knee-chest posture 

(Bumm). 



The patient should lie upon the sides or abdomen, and will often 
require the use of the catheter at regular intervals. 

If this does not succeed, the question of abdominal section must 
be seriously considered. If the uterus is not replaced, pressure will 
bring about hemorrhage into the decidua, the ovum will die, its dis- 
charge will be incomplete, and the operator will be confronted with an 
incarcerated septic uterus. Abdominal section or vaginal extirpa- 



54 OPERATIVE OBSTETRICS 

tion will then be indicated. To anticipate this condition, it is advis- 
able, where other means have failed, to open the abdomen and en- 
deavor to release the retroverted gravid womb. The patient should 
be placed in the Trendelenburg posture, the bladder having been com- 
pletely emptied by catheter, and when the abdomen is opened the 
operator should make a gentle but thorough effort to release the 
fundus. Adhesions ma}^ be separated by the fingers covered with 
gauze, or cautiously severed with blunt-pointed scissors. After the 
uterus has been replaced the tubes and ovaries should be examined, 
and if they are adherent they also should be loosened. A strand of 
iodoform gauze (10 per cent.) should be passed through the low^er 
end of the abdominal incision behind the fundus, serving as a drain, 
to check oozing from adhesions, and maintain the womb in its new 
position. This may gradually be removed in a few days following 
the operation. After such an operation the patient may be given 
morphin for a few days to prevent uterine contractions. 

Where the retroverted gravid womb has become infected and 
cannot be replaced, success has been reported by vaginal extirpation 
of the uterus. This is done in the usual manner, gauze packing 
being inserted to drain the pelvis and control oozing for several 
days after the operation. 

If the patient is in good general condition, an effort may be made 
to retain the uterus, although septic. The abdomen should be 
opened and the uterus replaced, gauze packing inserted, and brought 
out at the lower end of the abdominal incision; following this the 
mouth of the womb should be cautiously dilated through the vagina, 
debris brought away with a blunt curet, and a packing of iodoform 
gauze (1 per cent.) introduced within the uterine cavity. The vagina 
should be packed with bichlorid gauze to assist in maintaining the 
uterus in its new position. With this combined operation the uterus 
is drained, hemorrhage prevented, the womb is replaced, and the 
patient, in good condition, may thus recover, retaining the uterus. 

Retaining the Uterus in Normal Position After Retroversion 
During Pregnancy. — A retroverted gravid womb after replacement 



UTEHIXE DISPLACEMENTS 55 

may bo rctaiiKnl in position in the early wcn^ks of pregnancy by a 
suitable pessar3^ A retroversion pessary with a soft-rubber posterior 
bar is best adapted for this purpose. Vaginal douches of boric 
acid or 1 per cent, lysol must be taken daily to maintain cleanUness. 
The pessary should be removed as soon as possible. The perma- 
nent relief of retroversion by operation is rarely required during preg- 
nancy. The conditions are not favorable for such an operation, and 
it shoukl be resorted to only in extreme cases. Shortening of the 
round Hgaments or extensive repair of the pelvic floor is only justifi- 
able in extreme cases. After such a patient has passed through 
pregnancy and labor, she should then be subjected to intra-abdominal 
shortening of the round ligaments, or some other suitable operation 
for the permanent correction of the backward displacement. 

Prolapse of the Pregnant Womb. — Prolapse of the pregnant womb 
may be so pronounced as to cause the patient great inconvenience 
and threaten the termination of gestation. Such cases are most un- 
favorable for operation and should be treated by palliative measures, 
including rest in bed, wool tampons, and proper abdominal support. 
Should abortion occur followed by infection, the complete removal 
of the uterus would be indicated, followed by pelvic drainage. 

Hernia of the Pregnant Womb. — In anemic women, usually multi- 
para^ with separation of the recti muscles, abdominal hernia may 
include the pregnant uterus. The treatment of the condition must 
be palliative during pregnancy, and operation must be postponed 
until after the patient has recovered from labor. Relief during 
pregnancy may be obtained by suitable bandaging, w^hich should be 
worn during labor to facilitate the expulsion of the fetus. 

Bibliography of Uterine Displacements 
Baisch: Zeitschr. f. g. Urologie, Bd. 1, Heft 1, 1909. 
Bennecke: Zentralblatt f. Gynakologie, No. 23, 1906. 
Born: Zentralblatt f. Gynakologie, No. 4, 1907. 

Campbell: Jour, of Obstet. and Gynecol, of British Empire, Dec, 1909. 
Cooke: British Medical Journal, May 15, 1909. 
Couvelaire: Ann. de Gyn. et Obstet., March, 1909. 
Diebel: Archiv f. Gynakologie, Band 63, Heft 1 and 2, 1901. 



56 OPERATIVE OBSTETRICS 

Glinski: Przeglad Lekarski, Xo. 26, 1909. 
Henkel: Minchener m. Wochenschrift, Xo. 17, 1909. 
Littauer: Zentralblatt f. Gynakologie, X^o. 26, 1909. 
Lobenstine: American Journal of Obstetrics, Dec, 1909. 
MacXTanghton-Jones : British Medical Journal, May 11, 1901. 
Marschner: Zentralblatt f. Gynakologie, X^o. 38, 1902. 
Martin: La Gynecologie, July, 1909. 
Orthmann: Frauenarzt, Heft 10, 1909. 
Pestalozza: La Ginecologia, Januar}^ 15, 1907. 
Swayne: Bristol Medical Journal, Xov. 20, 1909. 
Thomson: Zentralblatt f. Gynakologie, Xo. 19, 1906. 
Zeigenspeck: Zentralblatt f. Gynakologie, X^o. 23, 1908. 

REPAIR OF LACERATIONS OF THE UTERUS DURING PREGNANCY 

The torn cervix, with enlargement of its mucous follicles and chronic 
catarrh, will usually be worse during gestation. If possible, opera- 
tion should be postponed until after labor. In extreme cases, where 
the torn cervix is so greatly enlarged that it assists in prolapse and the 
interruption of pregnancy is threatened, repair may be undertaken. 
Unusual hemorrhage is often experienced in such operations upon 
pregnant patients, and union is not always satisfactory. 

THE REMOVAL OF UTERINE TUMORS DURING PREGNANCY 

The occurrence of pregnancy in a fibroid uterus raises the question 
of operation during pregnancy, or of allowing the patient to go through 
labor with the hope that the fibroid will disappear during uterine 
involution. The choice of a method of treatment will depend greatly 
upon the situation of the fibroid. If it be upon the fundus or pos- 
terior wall of the uterus, and small in size, it will probabh^ occasion 
little or no discomfort during the pregnancy, will not complicate labor, 
and may remain quiescent indefinitely after the patient's recovery. 
If the fibroid is low upon the uterus, so that it will obstruct the passage 
of the child through the pelvis, and if multiple fibroids occur, occupy- 
ing a large part of the uterine tissue, the fetus will have difficulty in 
birth and uterine contractions will be deficient. Lender these cir- 
cumstances it may be best to allow the patient to go to term, dehver- 
ing her by abdominal and uterine incision, followed by hysterectomy. 



THE KEMOVAT. OF I TEHIXE '1 TMOHS DUKIXG rUEGNANCY 57 

Tlio ])rcgnant pationt having a fibroid tumor of considerable size is 
liable to complications at any time during pregnancy. Often in the 
early months such tumors may become wedg(Hl in the pelvis, as in a 




Fig. 4, — Uterus "vvith fibromyomata, and containing a full-time child, removed by 
panhysterectomy during labor (Bland-Sutton). 

case described by Bland-Sutton.^ This patient, a primipara in the 
fourth month, after a long motor-car journey, was taken with severe 

^ Jour. Obstetrics and Gyn., British Empire, December, 1907. 



5S OPERATIVE OBSTETRICS 

pelvic pain, vomiting, and abdominal distention. A large fibroid 
growing from the cervix had become firmly wedged in the pelvis. 
Hysterectomy was necessary to relieve the patient. 

An effort has been made to anticipate complications in labor 
by removing fibroid tumors in the pregnant womb by myomectomy. 




Fig. 5. — Fibromyomata associated with pregnancy (Kerr). 

This procedure is not entirely satisfactory, for small tumors rarely 
require removal during pregnancy, and the removal of large tumors 
is often followed by serious consequences. If large tumors be present 
it is best to allow the patient, if possible, to go to viability, and then 
deliver the child by abdominal section, followed by hysterectomy. 



THE REMOVAL OF UTERINE TUMORS DURING PREGNANCY 



59 



Pedunculated fibroids and iitc^rine i)olyps should be removed 
during pregnancy as soon as their (existence is discovered. This pro- 
cedure usually causes no disturbance. 

In dealing with cancer of the womb complicating pregnancy, the 
operator must carefully consider the period of gestation and consult 
the patient's wishes regarding the possible life of the child. If a 
pregnant patient comes under observation in the early months of 
gestation, and a positive diagnosis of carcinoma, sarcoma, or epithe- 



Myoina at the 
fundus 




Myoma in 
lower uterine 
segment 



Fig. 6. — Myomata complicating labor (Bumm). 

lioma of the uterus be made, it is undoubtedly wisest to sacrifice the 
uterus, by total extirpation. If, however, she presents herself late in 
pregnancy, within a short time of viability, the malignant growth in- 
volving the cervix, but not the body of the womb, she may decline 
extirpation of the uterus in the hope of obtaining a living child. 
Under these circumstances the fetus should be delivered when via- 
bility is assured by abdominal and uterine section, followed by the 
complete removal of the uterus. Formerly the effort was made to 



60 



OPERATIVE OBSTETRICS 




Fig. 7. — Flattened submucous myoma which simulated a prolapsed cord (Kerr). 



remove cancer of the cervix by cautery, in the hope of staying the 
progress of the disease and avoiding the interruption of pregnancy. 



THE REMOVAL OF UTERINE TUMORS DURING TREGNANCY 61 

Such interference, however, i.s i)racticiill3' useless and should not be 
adopted. 

Bibliography 

Audebert: British Medical Journal, Nov. 0, 1909. 

Barbour: Lancet, vol. 1, p. 512, 1907. 

Berger: Thesis, Paris, 1907. 

Bland-Sutton: Journal of Obstetrics and Gynecology of the British 

Empire, December, 1907; British Medical Journal, July 4, 1908, 

June 19, 1909. 
Bonnaire and Brindeau: Bull, de la Soc. d'Obstet. de Paris, No. 3, 1909. 
Brewis: British Medical Journal, vol. 1, p. SO, 1907. 
Burty: Thesis, Paris, No. 396, 1906 and 1907. 
Biittner: Deutsche med. Wochenschrift, vol. 33, p. 844, 1907. 
Cullen: Journal of American Medical Association, January 11, 1908. 
Declage and Gaujoux: Gazette Des hop., No. 50, 1907. 
Doran: American Journal of Obstetrics, vol. 55, p. 103, 1907. 
Iwanoff: Annal. des Gyn., vol. 4, p. 311, 1907. 
Joubert: Thesis, Paris, p. 317, 1906 and 1907. 
Kayser: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 25, 

Heft 1, 1907, and vol. 25, p. 76, 1907. 
Kerr: Zentralblatt f. Gynakologie, No. 14, 1909. 
Kufferat: Zentralblatt f. Gynakologie, No. 40, 1909. 
Lockyer: British Medical Journal, October 9, 1909. 
Mace: Ann. de Gyn. et Obstet., March, 1909. 
Mann: American Journal of Obstetrics, vol. 55, p. 737, 1907. 
McMurtry: Surgery, Gynecology, and Obstetrics, March, 1908. 
Michin: Festschr. von Ott, St. Petersburg, Part I, 1906. 
Piquand and Lemeland: L'Obstetrique, July, 1909. 
Pozzi: Zentralblatt f. Gynakologie, No. 40, 1909. 
Schiitze: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 25, 

p. 761, 1907. 
Simon: Miinchener med. Wochenschrift, vol. 54, p. 1071, 1907. 
Smyley: British Medical Journal, January 23, 1909. 
Spaeth: Deutsche m. Wochenschrift, No. 10, 1908. 
Spencer: Surgery, Gynecology, and Obstetrics, May, 1909. 
Speransky and Bachmetew: Zentralbl. f. GynakoL, No. 16, 1909. 
Stone: American Journal of Obstetrics, vol. 55, p. 229, 1907. 
Thring: Journal of Obstetrics and Gynecology of the British Empire, 

vol. 10, No. 3, 1907. 
Vineberg: American Journal of Obstetrics, vol. 55, p. 655, 1907. 



62 



OPERATIVE OBSTETRICS 



OPERATIONS UPON THE FALLOPIAN TUBES AND OVARIES 
Operations Upon the Fallopian Tubes During Pregnancy. — Infec- 
tion antedating pregnancy or accompanying it may cause salpingitis 
with infection of surrounding tissues. When such occurs, operation 
should not be immediately undertaken, in the hope that the inflam- 
mation may subside and the patient go on to term. If, however, the 
patient does not promptly improve, the infected tube should be 
removed with other surrounding tissue found to be infected also. 
If there is great adhesion in the pelvic viscera, with masses in the pel- 




Fig. 8. — Ovarian cyst complicating early pregnancy (Bumm). 

vis and the development of pelvic abscess, a conservative method 
should be followed. The pelvic cavity should be opened freely by a 
wide incision in the posterior vaginal fornix, and when the pus-tubes 
have been found and clearly located, they should be opened by blunt 
scissors and drained through the vagina. Care should be taken to 
avoid the intestines, and as little disturbance as possible of the pelvic 
organs should be practised. Hydrosalpinx, in the absence of acute 
infection, does not call for operation. 

Operations Upon the Ovaries During Pregnancy. — The ovary not 
the seat of tumor rarely requires operative treatment during ges- 



OPKHATIOXS UPON THE FALl.OPIAN Tl'HES AND OVARIES G3 

tat ion. In chronic salpingitis the ovaries may be lx)iin(l down by 
adhesions, and it is usually wiser to leave them in the abnormal 




Fig;. 9. — Ovarian cyst entirely in the pelvis. This tumor was pushed out of the 
pelvis in the second stage of labor, and the child extracted with forceps. The 
tumor was removed three weeks after the confinement by abdominal section (Kerr). 

position than to do violence by separating them. If a definite 
ovarian growih can be recognized, it should be removed as soon 
as possible, no matter what the period of pregnancy may be. 



64 OPERATIVE OBSTETRICS 

Ovarian tumors complicating pregnancy were formerly allowed to 
remain undisturbed through fear of interrupting pregnancy. In 
Flatau's collection^ of 284 cases of ovariotomy during pregnancy, 
the interruption of gestation occurred in 17 per cent. The abdominal 
route is far superior to the vaginal in ovariotomy during pregnancy, 
for interruption by the latter method occurred in 49 per cent. In 
removing ovarian tumors complicating pregnancy the extreme Tren- 
delenburg position should be avoided. The tumor should be care- 
fully and gently removed, the vessels in the pedicle being ligated sep- 
arately. All exposed points should be covered with peritoneum and 
stitched with catgut. Chloroform and oxygen is a good anesthetic 
for these cases, as cough and irritation are less than with the use of 
ether. The mortality for the children has been estimated between 
4 and 5 per cent. An additional reason for removing ovarian tumors 
complicating pregnancy lies in the possibility that twisting of the 
pedicle will occur, followed by necrosis and peritonitis. By some 
this is ascribed to the intermittent contractions of the uterus, and by 
others to the efforts of the uterus to accommodate itself to the abdom- 
inal cavity. The complication is of sufficient frequency to make the 
removal of every ovarian tumor complicating pregnancy advisable 
as soon as the diagnosis of the existence of the tumor can be made. 

Bibliography 

Andrews: British Medical Journal, vol. 2, p. 1584, 1907; Journal of 

Obstetrics and Gj^necolog}^ of the British Empire, October, 1909. 
Bircher: Zentralblatt f. Gynakologie, vol. 31, p. 1378, 1907. 
Birkhoven: Inaug.-Diss., Giessen, 1905. 
Burdsinski: St. Petersburg, Med. Wochens., vol. 32, 1907. 
Connel-Sheffield : Journal of Obstetrics and Gynecology of the British 

Empire, vol. 10, No. 2, 1907. 
Conway: Journal of Obstetrics and Gynecology of the British Empire, 

August, 1907. 
Cumston: Journal of Obstetrics and Gynecology of the British Empire, 

September, 1908. 
Davis: Surgery, Gynecology, and Obstetrics, May, 1909. 

1 Archiv f. Gyn., 1907, Band 82. 



OrERATIONS UPON THE PELVIC FLOOR DURING PREGNANCY 65 

Demsch: Moimtsschrift f. (Jcburtshiilfo unci Clynakologic, Band 2G, 

p. 143, 1907. 
Doran: Journal of Obstetrics and CJynccology of tlic British Empire, 

Februar>', 19()S. 
riatau: Arcliiv f. Ciynakologie, l^and S2, p. 452, 1907. 
(Jrad: Jour. Amer. Med. Assoc, November 27, 1909. 
Horn: Miinchener med. Wochens., vol. 54, p. 703, 1907. 
Kerr: Glasgow Medical Journal, September, 1907; Journal of Obstetrics 

and Gynecolog}' of the British Empire, January, 190(S. 
Kiistner: Zentralblatt f. Gynakologie, vol. 30, p. 1025, 1907. 
Kynock: Journal of Obstetrics and Gynecology of the British Empire, 

August, 190S. 
Liepmann: Zentralblatt f. Gynakologie, No. 11, 1907. 
Marshall : Journal of Obstetrics and Gynecology of the British Empire, 

February, 1910. 
Martin: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 25, p„ 

767, 1907; Archiv prov. de Chir., No. 2, 1907; Thesis, Lille, No. 

29, 1906 and 1907. 
Morestin: Annal. des. Gyn., Part 2, vol. 4, p. 602, 1907. 
Nijhoff : Zentralblatt f. Gynakologie, November 28, 1905. 
Oui: Annal. des Gyn., Part 2, vol. 4, 1907. 
Petri: Zentralblatt f. Gynakologie, No. 30, 1909. 
Pf annenstiel : Deutsche, med. Wochens., vol. 33, p. 1278, 1907. 
Petzloff : Monatsschrift f. Geburtshiilfe und Gynakologie, Band 25, 1907. 
Robb: Cleveland Medical Journal, June, 1907. 
Rushmore: Surgery, Gynecology, and Obstetrics, November, 1909. 
Sahnwalclt: Inaug.-Diss., Breslau, 1909. 
Schumann: Inaug.-Dissert., Marburg, 1906. 
Simon: Miinchener med. Wochens., vol. 54, p. 1209, 1907. 
Spencer: Surgery, Gynecology, and Obstetrics, May, 1909. 
Stirling: Intercol. Med. Jour, of Australasia, July 20, 1907. 
Treub: Zentralblatt f. Gynakologie, vol. 31, p. 1448, 1907. 
Weller: Inaug.-Dissert., Berlin, 1906. 
Widmann: Inaug.-Dissert., Freiburg, 1905. 
Zemmel: Lancet, vol. 1, p. 27, 1907. 
Zickel: Zentralblatt f. Gynakologie, No. 14, 1907. 

OPERATIONS UPON THE PELVIC FLOOR AND PERINEUM DURING 

PREGNANCY 

Where extensive laceration has occurred in previous labors, and 
the uterus is prolapsed and abortion threatened, it may be neces- 
sary to repair the pelvic floor during gestation. The usual operation 

5 



66 OPERATIVE OBSTETRICS 

may be done, taking care to avoid extensive denudation and the form- 
ation of a rigid perineum, which will tear at the termination of preg- 
nancy. If, in addition to her lacerated state, the woman be in bad 
general health, good union can scarcely be expected. During such 
operations it will be necessary to control hemorrhage carefully and to 
operate as quickly as possible, as the tissues are unusually vascular 
and severe blood loss may occur. 

OPERATIONS UPON THE RECTUM DURING PREGNANCY 
Many pregnant patients suffer from hemorrhoids, in some cases 
complicated by eversion of the mucous membrane and great irrita- 
tion. The operator may be strongly tempted to operate in these 
cases, ligating and removing hemorrhoids or dissecting out the mu- 
cous membrane of the rectum with its enlarged veins. The interrup- 
tion of pregnancy so often follows this operation that it is to be avoided 
and the patient's condition palliated until the pregnancy has ended. 
Should hemorrhage occur from bursting of the hemorrhoids or acci- 
dental wounding, the individual tumor should be ligated under anti- 
septic precautions. 

EMPTYING OF THE UTERUS BEFORE VIABILITY; THERAPEUTIC 

ABORTION 

Therapeutic abortion is indicated when the pregnant woman's life 
is threatened by a serious condition found in pregnancy only. The 
most frequent state requiring therapeutic abortion is the toxemia 
of pregnancy, with or without pernicious nausea. The decision to 
operate in these cases must not be made hastily. The patient should 
have been under observation for several days. The blood should 
have been thoroughly examined, a nitrogen partition of the urine 
made, accurate records kept of the amount of nourishment taken, 
the blood-pressure recorded, and the patient's condition accurately 
ascertained. The statement that the patient can retain nothing, made 
by herself and her friends, that she vomits constantly, that she can- 
not sleep, that she cannot endure the pregnancy, such remarks are 
to be taken not to indicate her real condition, but her unwillingness 



EMPTYING OF THE UTERUS BEFORE VIABILITY 07 

to go through gestation. When a i)r('gnaiit i)ati('nt has (lovolo])ing 
pernicious anemia, with profound disturbance in the nitrogenous 
excretion, inability to assimilate food, and dei)ression of the nervous 
system, which these conditions cause, delay should cease. 

Acute tuberculosis is also a justifiable cause for therapeutic abor- 
tion; so is a mental or nervous condition in the moth(^r, which would 
be transmitted to her offspring, resulting in insanity or constitutional 
nervous disorder. 

Contracted pelvis is not an indication for therapeutic abortion, 
nor is the presence of a fibroid tumor in the w^omb, an ovarian tumor, 
or cancer of the womb. Therapeutic abortion should not be prac- 
tised in the acute infections, as it tends to increase the burden under 
which the patient labors. 

Care should be taken not to attempt therapeutic abortion by slow 
and uncertain methods. The introduction of sounds and tents is 
unsatisfactory and should be rejected for more efficient procedures. 
It will be remembered that it is impossible to empty the uterus by 
any one procedure, but that the life of the embryo can be interrupted 
and the uterus be put in the most favorable condition possible for 
the discharge of the deciduous membranes. 

In selecting an anesthetic for therapeutic abortion, the condition 
of the patient must be considered. Bronchial infection or irritation 
suggests the employment of oxygen and chloroform. Toxemic con- 
ditions contraindicate the use of chloroform, because of the danger 
of acidosis and acetone intoxication. If chloroform be selected, it 
should be largely diluted with oxygen. 

The patient should be prepared for operation in the manner usual 
for any vaginal procedure. After catheterization and under anti- 
septic precautions, the uterus should be dilated sufficient^ with 
solid bougies to permit the introduction of a blunt curet. With this 
as much as possible of the ovum should be removed, and the uterus 
irrigated and packed firmly with 10 per cent, iodoform gauze. The 
vagina should be packed with bichlorid gauze, and carried into a 
position favorable for drainage. Gauze packing should be allowed 



68 OPERATIVE OBSTETRICS 

to remain undisturbed for from thirty-six to forty-eight hours; it 
may even remain seventy-two hours without danger, if the patient 
receives good aseptic care. Tonic doses of strychnin and ergot should 
be given to promote uterine contractions. Upon removing the 
gauze the embryo will accompany or shortly follow it, and involu- 
tion will go on much more promptly than in cases where the packing 
has not been used. Occasionally, it is necessary to repack the uterus 
because all of its contents does not come away, and hemorrhage 
may occur. Such packing may remain forty-eight hours, when, upon 
its removal, the uterine contents is usually found adherent to the 
gauze. This method of emptying the womb in the early months 
of gestation has proved satisfactoiy. The administration of drugs 
is too uncertain and dangerous, and the introduction of tents and 
bougies too slow and inefficient to be recommended. 

In cases where the cervix is so resisting that it cannot be dilated 
sufficiently for cureting and the introduction of gauze, Ne well's dila- 
tor or Bossi's dilator may be employed. Both should be used with 
caution, the latter especially, because considerable laceration of the 
cervix may result. It is occasionally necessary to incise the cervix, 
or to perform vaginal Cesarean section, because the uterus cannot 
safely be dilated. Should serious laceration of the cervix occur dur- 
ing operation, it should be closed with chromicized catgut. The 
operator should be sure of his ground before performing therapeutic 
abortion. This is possible only in cases where the patient is under 
accurate observation, and where accurate records are kept. 

In cases where viability is not present, and pregnane}^ must be 
interrupted after the early months of gestation are past, the operator 
must secure sufficient dilation, if possible, to remove the fetus at 
the time of operation. This can be done b}^ Bossi's or Ne well's dila- 
tor, by incising the cervix, or by vaginal Cesarean section. In deliv-, 
ering the premature fetus, the danger of dismemberment must be 
kept in mind, as a severed head is sometimes left within the womb. 
As the life of the fetus cannot be saved, extraction should be made 
slowly and carefuhy by pulhng upon the lower extremities, and care 



KMI'TYIXG ITKHIS AP^TEll VIAIHLITY AND BEFORE FULL TERM 69 

taken to dilate the eervix thoroughly to secure the extraction of the 
head. If this be left behind, it may be removed by the placental for- 
ceps or by the cranioclast, or by long curved forceps with serrated 
blades. Should this not readily be accomplished, the operator can 
pack the cervix and uterine cavity as firmly as possible with 10 
per cent, iodoform gauze. The uterus will dilate and expel its 
contents. Under antiseptic precautions portions of the fetus may 
remain within the womb for several da3^s without the development 
of infection. 

EMPTYING THE UTERUS AFTER VIABILITY AND BEFORE FULL 
TERM; THE INDUCTION OF LABOR 

No operation has had made for it greater claims than the induc- 
tion of labor. In some quarters it is supposed to be a panacea for 
contracted pelvis and the complications which full-term pregnancy 
produces. In properly selected cases and in good hands it is undoubt- 
edly a valuable and justifiable operation, but improperly applied it 
increases fetal moi-talit}' and maternal morbidity, causes the mother 
great sufTering, and results in a labor which is usually artificial and 
often prolonged. 

A common indication for the induction of labor is disproportion 
between mother and child. This ma}^ arise because the fetus is over- 
grown or because the mother is undersized. In the former, preg- 
nancy has usually gone be3^ond its natural limit ; in the latter labor is 
usually induced before full term has arrived. Labor is also induced 
for conditions in the mother which threaten her life if pregnancy be 
prolonged. Heart lesions with failing compensation, tubercular 
infection, rapidly developing toxemia, and profound anemia may 
require the termination of pregnancy prematurety; and on the side 
of the fetus, habitual fetal death at a certain period in gestation may 
cause pregnancy to be terminated before that time, with the hope 
of securing a viable child. Labor is also induced in cases where the 
mother has previously had a difficult confinement terminating in the 
birth of a dead child, and where large development of the fetus and 



70 



OPERATIVE OBSTETRICS 



slight pelvic contraction or abnormality have produced fatal birth 
pressure. The induction of labor is here based upon the hope that the 




Fig. 10. — The diameters of the pelvic outlet (Bumm). 

smaller fetus with softer bones will pass safely through the birth- 
canal. 



®<^ 



^ 




Fig. 11. — Measurement of the anteroposterior diameter of the pelvic outlet (Bumm). 

Labor is induced in primiparous patients where slight dispropor- 
tion between mother and child is present; such may be termed pro- 



EMPTYING UTERUS AFTER VIABILITY AND BEFORE FULL TERM 71 

phylactic induction of labor in comparison with prophylactic version. 
Its object being to deliver the smaller child with soft(4' bones, avoid- 
ing the risk of birth pressure at full term. 

The induction of labor is not to be confounded with the rapid 
emptying of the pregnant uterus, accouchement force, which has long 
been practised in obstetric emergency. The induction of labor en- 
deavors to imitate spontaneous parturition, the gradual beginning of 





Fig. 12. — Measurement of the transverse diameter of the pelvic outlet (Bumm). 

uterine contractions, gradual dilation of the birth-canal, and the 
expulsion of the child by the mother's spontaneous efforts. 

The Time for Inducing Labor. — Two methods of choosing the 
time for the induction of labor are employed. In one the pelvis is 
measured as accurately as possible, and the true conjugate is taken as 
the most important diameter. If this be less than 8 cm. (3 J inches) , 
the induction of labor with the hope of obtaining a vigorous child 
may be decUned. If the true conjugate measures between 8 and 9 cm. 



72 



OPEEATIVE OBSTETRICS 



the induction of labor should be practised, as nearly as can be ascer- 
tained, between the thirty-second and thirty-fourth weeks of ges- 
tation. Where the true conjugate measures from 9 to 10 J cm. the 
induction of labor may be practised at the thirty-sixth week. On 
the average, such methods give the best results in the majority of 
cases. Their success depends upon an accurate history, giving precise 
information concerning the duration of pregnancy, an accurate meas- 
urement of the pelvis, and the records of the size of the fetus, obtained 
by a number of careful examinations. When one recahs how impos- 



^ 

^...m 




Fig. 13. — Internal measurement of the anteroposterior diameter of the pelvic inlet 

(Bumm). 



sible it is to tell the exact period of gestation, it is readily seen that 
errors may arise which may cause labor to be induced too soon or too 
late. 

Mueller's Method. — A second method of estimating the time for 
the induction of labor consists in fitting the head into the pelvis 
by suprapubic pressure, commonly known as Mueller's method. 

The patient should be prepared for this examination by empty- 
ing the intestine and urinary bladder, and if she is excessively nervous 
or apprehensive she should be anesthetized. The hands of the 



EMPTYING UTEKUS AFTKR VIAIUMTY AND BEFORE FULL TERM 73 

obstetrician arc made aseptic and the patient's abdomen is covered 
by one thickness only of pliable linen. The patient is then placed 
across a bed or upon a table, with the lower extremities flexed. The 
obstetrician introduces two fingers of one hand into the vagina, 
against the fetal head, and ascertains its position at the pelvic brim. 




% 




Fig. 14. — Internal measurement of the anteroposterior diameter of the pelvic inlet 

(Bumm). 

With the other hand by suprapubic pressure the head is gently 
carried downward and backward into the pehdc brim. With the 
two hands the ease or difficulty with which the head engages and 
passes clowTi, and its relative size in comparison with that of the 
pelvis, are thus ascertained. 

To be of practical value this examination must be repeated at 



74 



OPERATIVE OBSTETRICS 




Fig. 15. — Diameters of the pelvic inlet (Farabeuf and Varnier). 




Fig. 16. — -The practicable diameter of the pelvic inlet (Farabeuf and Varnier). 



intervals of ten days to two weeks; in cases of moderate pelvic con- 
traction, from the thirty-fourth to the fortieth weeks of gestation. 



EMPTYING UTERUS AFTER VIABILITY AND BEFORE FULL TERM 75 

AMien the head enters the pelvic brim with (Ufficulty, labor should 
be induced as soon as possible. In using this test the obstetrician 




/nf.' externa/ face ^ 

pyecoctygea/ fasaoy 

^(XcruntV, 

Fig. 17.— The pelvic outlet before the retropulsion of the coccyx (Farabeuf and 

Varnier). 




Inf.-ext face of^ 
Jn. le-votot anl 



precoccypea/ fasc/'a <?/ , ^ - 



t.SOcra-sc/atic l/^. 



retro flexec/ coccyA 

Fig. 18. — The diameters of the outlet after the retropulsion of the coccyx 
(Farabeuf and Varnier). 



must study the way in which the head presents at the pelvic brim. 
If, by pressure upon the occiput, he can make the occiput descend 



76 OPEEATIVE OBSTETRICS 

or the head partially wigage in one of the oblique diameters, the 
indications are favorable for delivery by induced labor. If, how- 
ever, the vertex will not descend, but the parietal bone comes down 
through lateral obliquity, the indication is that there is such dis- 
proportion between head and pelvis that an imfavorable presenta- 
tion and mechanism should be expected during labor. 

While Mueller's method is most valuable, it is evident that it is 
not an exact test, its frequent repetition is annoying to the patient, 
and it cannot be relied upon as a positive demonstration that vaginal 
delivery is possible. 

The Test of Labor. — If the obstetrician declines to induce labor 
at a fixed time, based upon pelvic measurements and the probable 
aize of the child, and if Mueller's method does not seem practical, 
thexe remains the most reliable of all tests, that of actual parturition. 
In this the patient is kept in the best possible physical condition, 
is urged to exercise freely, and the bowels are made to move 
thoroughly. If possible, the patient should take exercise with the 
trunk of the body forward upon the pelvis, thus furthering the 
descent and engagement of the head in the pelvic brim. Walking 
is also excellent. The patient must be so placed that the obstetrician 
can perfoim any operation necessary when labor develops. He 
should be summoned as soon as parturition begins. When a reason- 
able time has elapsed, with efficient pains to secure engagement, 
and engagement fails, the obstetrician may then elect abdominal or 
pubic section, in accordance with the circumstances of the case. 
By this method the number of operations will be reduced as low as 
possible, and the best results will be obtained for both mother and 
child. These cases should be sent to hospital for confinement, where 
abundant facilities for the best surgical work can be always in readi- 
ness. 

Methods for the LaductLon of Labor. — ^The introduction of a sterile 
bou^e or bougies into the uterus is unquestionably the safest method 
for the induction of labor. Its success depends upon the fact that the 
bougie irritates the uterine muscle, producing uterine contractions, fol- 



EMl^YIXG UTERU^i AFTER VIABILITY AND BEFORE FULL TERM < t 

IowchI by dilation of the cervix. As the induction of labor is based upon 
the theory of exciting uterine contractions, that method will Ix' most 
successful which directly stimulates the uterine muscle. No pro- 
cedure wliich dilates the cervix only can result in the successful in- 
duction of lalx)r. The uterine muscle acts by stimulation from the 
nervous ganglia l3eneath the muscle bundles, and if these are irri- 
tateil the muscle is stimulated and contracts. The action of bougies 
is so uncertain and tedious and at times painful that, if this method 
is selected, as many bougies as can be introduced should l^e employed, 
tlu'ee and sometimes four may be used \\*ith advantage. 




Fig. 19. — ^The diameters of the fetal head (Farabeuf and "Gamier). 

If gauze l^e introduced witliin the cervix and carried witliin the 
ca^^ty of the womb, uteiine contractions "^ill ultimately come on. 
This method, however, is more tedious than the use of bougies, and 
is appUcable only when, through hemorrhage or some other cause. 
gauze pressure is neces.sar}'. 

The mtroduction of other substances within the uteiiis to produce 
contraction has not been found satisfactory'. Sterile glycerin has been 
injected toween the membranes and the wall of the uterus, produc- 
ing uterine contraction. If the membranes be ruptured and consid- 



78 



OPERATIVE OBSTETRICS 



erable amniotic liquid be allowed to escape, the uterus will ultimately 
contract. This method is exceedingly dangerous for the fetus, very 
uncertain, and should not be practised except in cases of acute in- 
fectious diseases, where it may be necessary to sacrifice the Ufe of the 
fetus in the interests of the mother. The expulsion of the fetus is 
very gradual in these cases, and the method cannot be used with the 
hope of obtaining a living child. 




Fig. 20. — The diameters of the pelvic excavation (Farabeuf and Varnier). 



To hasten the induction of labor dilating bags may be introduced 
into the cervix when bougies are inserted into the cavity of the womb. 
These may be distended at intervals with sterile water and the course 
of labor thus rendered shorter. The introduction of bags adds con- 
siderably to the patient's pain and in some cases stimulates uterine 
contractions markedly, and in others produces very little effect. It 
is in some cases disappointing to find that when the bags are re- 



EMPTYING UTERUS AFTER VIABILITY AND BEFORE FULL TERM 79 

moved the partly dilated cervix contracts to almost its original 
proportions. 

The Technic of the Induction of Labor. — The patient should be 
prepared for the induction of labor by emptying the lower bowel 
thoroughly with purgatives and high injections. The patient's diet 
should be liquid. The external parts should be prepared by shaving 
and scrubbing with soap and water, sterile water and bichlorid (1 : 2000) . 
In healthy women a vaginal douche of 1 per cent, lysol, given gently, 
is sufficient; if the patient has had a profuse vaginal catarrh, suggest- 
ing endocervicitis during pregnancy, a douche of green soapsuds 
should be given, followed by boiled water and then by bichlorid solu- 
tion (1 : 4000) . It is well to introduce bougies just before the patient's 
bedtime, so that preliminary softening and dilation of the cervix 
may occur during the night. In some cases the cervix is sufficiently 
dilated to permit the introduction of bougies without anesthesia. 
In many cases brief anesthesia is necessary. This may be effected 
by chloroform or chlorid of ethyl, the patient placed upon her back 
at the edge of a bed with her limbs properly separated. Bougies 
cannot be boiled, as heat destroys their coating and elasticity. They 
may be thoroughly washed in soap and water and soaked in bichlorid 
solution (1 : 1000). The operator may require a speculum, uterine 
dressing forceps, uterine dilators, 10 per cent, iodoform, or sterile 
gauze and scissors. Tenaculum forceps are needed in many cases. 
If the cervix does not require dilation one or two fingers of one 
hand should be passed through the cervix, and with these fingers the 
OS dilated as much as possible without rupturing the membranes. 
Without removing the fingers, a bougie is then placed along the palm 
of the inserted hand, rotating it, and allowing it to pass gently between 
the membranes and the wall of the uterus. Should it meet obstruc- 
tion it should be partially withdrawn and introduced in another direc- 
tion. The operator must remember that there is slight danger of 
separating the placenta with the bougies, and also of rupturing the 
membranes. Both of these accidents are avoided by patience and 
gentleness. An inch of the bougie may be left protruding from the 



80 OPERATIVE OBSTETRICS 

external os. The operator may then insert two or three in addition 
to the first, letting them go into any portion of the uterus where they 
find least resistance. It is well not to insert a bag in these cases until 
the cervix has been softened by uterine action during the night, fol- 
lowing the introduction of bougies. These should be kept in place 
by a moderate vaginal packing of sterile or 10 per cent, iodoform 
gauze. A sterile vulvar dressing should be applied. 

During the night following the introduction of bougies the patient 
will often require sedative medicine to procure rest and sleep — 10 
gr. of veronal with milk or broth may be given or, if the patient 
be excitable and nervous, J gr. of codein. If the bladder can- 
not be spontaneousty emptied, a catheter should be used, at leasl 
once during the night. The nurse should be instructed to watch for 
vaginal hemorrhage, the occurrence of active uterine contractions, 
or the development of abdominal pain or tenderness. On the morn- 
ing following the introduction of bougies the cervix will usually be 
found softened and somewhat dilated, uterine pains will sometimes 
develop regularly, but in other cases are scarcely present. Within 
twelve hours after the first introduction, the bougies should be re- 
moved and a vaginal douche of lysol (1 per cent.) given, and bougies 
or dilating bags or both should be again inserted. 

In cases where the bougies must be introduced with instrumental 
dilation, the patient should have chloroform or ethyl chlorid, and 
the cervix dilated sufficiently to permit the introduction of sev- 
eral bougies. A bladed dilator, such as Bossi's or Newell's, may 
be used, care being taken to dilate very gradually and to carry 
the dilation only sufficiently far to permit the introduction of 
bougies. 

After the removal of the first bougies, if pains are occurring regu- 
larly, the cervix dilating, and the membranes protruding into the 
cervix, and the general condition of the patient good, four bougies 
may again be inserted, accompanied by a packing of 10 per cent, 
iodoform gauze, filling the cervix as completely as possible. The 
patient may sit up if she desires and walk about slowly, but should 



E-Ml'TVIXC, UTEIU'S AFTER VIABILITY AXD BEFORE FULL TERM 81 

be caiitioiUHl not to iiuikc violent niovenuuits, to avoid rupturing 
the membranes. 

If as little time as possible must be occupied in the induction of 
labor, after the cervix is softened by bougies, dilating bags may be 




Fig. 21. — Dilation of the cervix by de Ribes' bag (Bumm). 

used; such are, De Ribes', McLean's, ^^oorhees', Pomeroy's, and 
others devised by various operators. De Ribes' bag is inelastic 
silk, covered with rubber, and exerts constant and severe pressure. 
Other bags employed are elastic, made of rubber. The advantages 
6 



82 OPERATIVE OBSTETRICS 

of the use of bags, with bougies, are their almost continuous action, 
freedom from laceration of the cervix, stimulation of uterine contrac- 
tion, stimulation of mucous secretion in the cervix, and imitation, so 
far as possible, of the dilating action of a bag of water. In Pomeroy's 
double bag, the cervix and vagina both may be dilated by introducing 
sterile fluid into the two portions of the bag; by making traction 
upon the bag thi^ough its tube, increased dilating power is obtained 
and the whole birth-canal from the internal os is opened for the pas- 
sage of the child. 

When dilation by the use of bougies and bags has reached 
three-fourths of the capacity of the cervix, if the membranes are 
unruptured, it is well to remove the bougies and bags and allow the 
membranes to protrude through the cervix. The presence of bougies 
and bags sometimes disturbs the mechanism of labor, interferes with 
rotation, and may produce complications in the expulsion of the 
child. Hence, when labor has been thoroughly established and dila- 
tion three-fourths complete, it is well to remove the bougies and 
bags to give opportunity for the normal mechanism of labor. Strych- 
nin, ^\ gr., with 30 drops of aromatic spirits of ammonia and 30 drops 
of brandy, will usually stimulate uterine contractions sufficiently. 

If the operator has been unfortunate enough to rupture the mem- 
branes during induced labor, the use of the bags must be continued 
longer, and the largest size bags possible must be used to secure 
thorough dilation. The patient's suffering will be greater, labor will 
often be longer, the mechanism of labor altered, and the extraction 
of the child usually more difficult in these cases. 

The Termination of Induced Labor. — Theoretically, induced 
labor terminates with the spontaneous expulsion of the child. 
Practically, induced labor is frequently terminated by some other 
obstetric operation, usually the appHcation of forceps. 

A reason for the failure of induced labor to end spontaneously 
lies in the tedious suffering which it imposes upon the patient. Uter- 
ine contractions caused by bougies are usually not violent, but are 
prolonged and tedious, disturbing her rest and wearying and clis- 



EMPTYING UTERUS AFTER VIABILITY AND BEFORE FULL TERM 83 

couraging her. The use of bags causes great i)ain, and during their 
presence it is often nec(\s-^arv to give niorphin in J gr. doses to 
sensitive and excitable patients. The long and i)ainful labor result- 
ing from the use of bougies and bags wearies the patient and spon- 
taneous labor fails. When, therefore, the obstetrician commences 
the induction of labor, he must be prepared to terminate it b}^ some 
other obstetric operation to deliver" the child. During induced 
labor the patient's strength must be preserved b}' the frequent ad- 
ministration of liquid food, by securing as much rest as possible under 
the circumstances, and by avoiding all unnecessary interference and 
disturbance. The use of an anesthetic in introducing the bougies 
and dilating the cervix is most useful in all patients who suffer 
acutely. 

The Results of Induced Labor. — The copious literature of this 
subject furnishes papers giving the results of accurate observation. 
From these the frequency of induced labor may be estimated and 
its value as an obstetric operation. Williams/ in 5000 cases of labor, 
induced labor 11 times. The indications were diseases of the heart, 
preeclamptic toxemia, the presence of a dead fetus, polyhydramnios, 
infection, and overgrowth of the child. The mothers recovered. 
The cervix was slightly torn in 2 cases, uninjured in the remaining 9. 
The induction of labor was not practised for pelvic contraction. 
Moller,- in 21,066 births, found 80 cases of induced labor in the Copen- 
hagen Clinic. Among these were 646 cases of pehic contraction, which 
would bring the induction of labor once in 8.73 cases of contracted 
pelves. Among these patients the head presented in 67.5 per cent. ; 
the breech in 32.5 per cent. In 14 cases in which the head presented 
the mechanism was unfavorable, and in 10 of these dilating bags were 
used during labor, thus illustrating the tendency of bags to interfere 
in the mechanism of labor; 52.5 per cent, of labors terminated spontan- 
eously ; 47.5 required other operation. The maternal mortality was 1.25 
per cent.; the maternal morbidity 33.75 per cent. The mortality for 

^ Surgery, Gynecology, and Obstetrics, September, 1906. 
2 Archiv f. Gyn., Band 80, Heft 3, 1906. 



84 OPERATIVE OBSTETRICS 

the child was 18.75 per cent. The period most often chosen was 
the thirty-fifth week. One year after tlie operation it was found that 
20 per cent, less of the children born by induced labor survived than 
among children born spontaneously. In cases where the induction of 
labor was practised later than the thirty-fifth week, the mortality 
among the children was increased, von Herff ^ had a fetal mortality 
of 20 per cent, in the induction of labor. He estimates the maternal 
mortality in induced labor at a rate fully as liigh as that of other 
major operations. Leopold,' in 14,094 births, induced labor for con- 
tracted pelves 87 times. In common with many German obstetri- 
cians he induced labor in cases having a comparatively small true con- 
jugate, thus the range in the measurement of the true conjugate ex- 
tended from 8.5 to 7.5 cm. In the smaller pelves the induction 
of labor was terminated by some other operation, usually hebotomy. 
He chose the thirty-fifth to the thirty-sixth week as the best period : 

85 per cent, of the children were born Hving; 15 per cent, were still- 
born. During the first ten daj^s after birth 13 children, or 18 per 
cent, of the entire number, died; 69 per cent, of the children left the 
hospital in good condition. Labor was induced by bougies alone in 
5 cases; bougies and bags in 12; Bossi's dilator and bag in 52, and the 
use of bags only in 15. The maternal mortalit}^ was 1.2 per cent.; 
maternal morbidity 28.5 per cent. Leopold has been especially in- 
terested in the fate of children born in premature labor. He in- 
vestigated 353 cases and found at the end of the first year 20.9 per 
cent, of these had died. In the series of cases just mentioned 24.4 per 
cent, of the children did not survive the first 3^ear. Leopold beUeves 
that the operation has its distinct place, but should not be applied 
in cases of primiparse with contracted pelvis. It finds its especial 
field in multiparse where pelvic contraction is not extreme, and where 
patients have lost children in prolonged and difficult labor. 

The Value of Induced Labor. — No subject is at present more 
debated than the indications for and the value of induced labor. It 

1 Monatsschrift f. Geb. u. Gyn., 1907, Band 24, Heft 6. 

2 Archiv f. Gyn., Band 81, 1907, 



EMPTYING UTERUS AFTER VIABILITY AND BEFORE FULL TERM 85 

has lately conic into competition with ('csai(>an sc^ction and pubiot- 
oniy, whose results are now so good as to challenge those of induced 
labor. In contracted pelves in })riinipara} the majority of opinion 
among operating obstetricians to-day is against interference, if pos- 
sible. Abundant statistics show tliat in large series of contracted 
pelves spontaneous labor occurs in (SO })er cent. The mortality and 
morbidity for the children in these cases is sur])risingly little. If 
cases of pelvic contraction can be brought under observation early 
in pregnancy, the mother's diet be regulated, she be made to exer- 
cise regularly, and her general vigor maintained, four-fifths of these 
cases will deliver themselves. 

We are still without accurate methods of fetometry ; in their ab- 
sence our one rehable measurement of the comparative size of mother 
and child is the development of labor. In cases of extreme pelvic 
contraction this, of course, does not apply, but we are speaking of 
moderate pelvic contraction, in which the decision is most difficult. 
The development of labor has the advantage of bringing the child 
do^^TL from above into the pelvis, developing molding of the head and 
the accurate fitting of the presenting part into the pelvic cavity. 
No artificial method of delivery accomplishes this. In moderate 
pelvic contraction we cannot know that the head will not enter the 
pelvis until a reasonable time has elapsed, with uterine and abdominal 
contractions carrying the child downward. 

In multiparse with moderate pelvic contraction, with a history 
of disastrous labor, the induction of labor may be most valuable. 
Here the mother's mind will be greath^ relieved to find that without 
an abdominal section she may have a child with every prospect of 
success. She will cheerfully submit to the necessar}- manipulations, 
and the indications seem all in her favor. It must not be forgotten, 
however, that in almost half of these cases delivery must be termi- 
nated by forceps or Aversion. In cases where serious and progressive 
disease threatens the life of the mother, or where some diseased con- 
dition threatens the chikl, the induction of labor is most valuable. 
In these cases the child's life cannot be considered, and delav mav be 



86 OPERATIVE OBSTETRICS 

practised to secure the gradual expulsion of the fetus with the least 
disturbance and risk to the mother. 

The Induction of Labor as Preliminary to Other Operations. — 

The obstetrician is called upon to deal with cases where pregnancy 
may be interrupted with the hope that spontaneous labor will occur, 
but with the well-grounded fear that such will not be the case. With 
such patients the obstetrician must carefully weigh the circumstances 
and factors present. If the parents greatly desire a hving child, should 
complications arise during induced labor threatening the child's Hfe, 
the obstetrician must be prepared to deliver it as soon as possible in 
the safest and best way. Pubiotomy and forceps or Cesarean sec- 
tion may become indicated. 

In induced labor great care must be given to antiseptic precau- 
tions. The fact that a second operation may be necessary to secure 
delivery renders it imperative that the birth-canal be maintained 
in an aseptic condition. Artificial dilation frequently causes sUght 
lacerations of the birth-canal, which are an open door for the en- 
trance of infection. 

The Choice of Induced Labor. — In deahng with married patients 
with whom the life of the child has definite value, induced labor 
should not be advised as the safest operation for the infant. Its 
mortality rate for the mother should be stated to the parents, and also 
its mortality rate for children. The mortality rate of other operations 
for mother and child should also be stated, and among intelUgent 
parents a decision advised may be given, supplemented by the choice 
of the patient and her husband. It seems but fair that obstetricians 
should state to patients, where such an important decision is to be 
made, their individual results of operations, thus giving a fair idea 
of what they can do for their patients. 

The Care of the Child in Induced Labor. — As the child is to be 
premature, it will require especial attention in these cases. It is 
essential that the nurse be accustomed to the care of premature in- 
fants ; the simplest and most efficient appliances for keeping the child 
warm should be in readiness. Usually for the first few days a basket 



EMPTYING UTERUS AFTER VIABILITY AXI) BEFORE FULL TERM 87 

filled with hot- water bottles may be employed, after which, if desired, 
an incubator may be used. In winter a constant and appropriate 
source of heat, a sunny room, stimulants, and an abundant supply of 
fresh air are recjuisite. AVhen it is possible, two nurses should have 
charge of mother and child, one to give her attention exclusively to 
the infant. 




Fig. 22. — Incubator with child wrapped in cotton, surviving after a difficult forceps 

extraction. 

The Induction of Labor for Fetal Deformity. — In these cases the 
life of the fetus is necessarily sacrificed, and the operator should be 
prepared to terminate the labor by embryotomy. In polyhydram- 
nios the possibility of twin pregnancy should not be forgotten, and 
also the fact that the fetus is often malformed and shares the disease 
of the mother. 

Bibliography of the Interruption of Pregnancy, Therapeutic 
Abortion, and the Induction of Labor 

Baisch: Archiv f. Gynakologie,, Band 84, Heft 2, 1908. 
Bokelmann: Graefes Sammlung, Band 7, Heft 6, 1907. 



55 OPERATIVE OBSTETRICS 

Biirger: Monatssclirift f. Geburtsliiilfe unci Gynakologie, Band 27, Heft 

6,, 190S; Monograph Wien., 190S. 
Cliazan: Zentralblatt f. Gynakologie, Xo. 3, 1909. 
Clirobak: Zentralblatt f. Gynakologie. Xo. 22, 1907. 
Cooke: American Journal of Obstetrics, June, 1907. 
Davis: Journal Amer. Medical Association, Xo. S, 1909. 
Discussion: Monatsschrift f . Geburtsliiilfe und Gynakologie, Band 2-1, 

Heft 4, p. 521, 1906; Zentralblatt f. Gynakologie, Xo. 16, 1907. 
Fraenld: Medicin. Ivlinik, 1907; Zentralblatt f. Gynakol., Xo. 31, 1907. 
Franz: Deutsche m. Wochenschrift. Xo. 26, 1909. 
Freitag: Inaug.-Disseit., Breslau, 1906. 
Fritsch: Deutsche m. AVochenschrift, Xo. -17, 1908. 
Grasser: Zentralblatt f. Gynakologie, Xo. 25, 1909. 
Hannes: Miinchener med. Wochens., p. 1974, 1907. 
Hense: Zentralblatt f. Gynakologie, Xo. 29, 190S. 
Hofmeier: Zeitschrift f. Gel^intshiilfe und Gynakologie, Band 59, 

Heft 2, 1907. 
Jewett : American Journal of Obstetrics, vol. 55, p. 769, 1907. 
Johnson: St. Paul Medical Journal, April, 1907. 
Labourdette: Bull, de la Soc. d'Obst. de Paris, Xov., 1909. 
Leopold and Conrad: Arcliiv f. Gynakologie, Band SI, Heft 3. 1907. 
Lobenstine: BuUetin of the Li-ing-In Hospital, Xew York, Sept., 190S. 
Lucas-Championniere : Ann. de Gyn. et Obstet., Feb.. 1909. 
Maygrier: L'Obstetrique. Xo. 4, 1907. 
Mueller: Monatsschrift f. Geburtsliiilfe und Gynakologie, Band 25, 

Heft 2. 1907. 
Miiher: Arcliiv f. Gynakologie, Band SO. Heft 3. 1906. 
Pinto: La Rassegna. d'Ostetr. e Ginec. vol. 16. pp. 129 and 300. 1907, 
Planchu: Jour, of Obstet. and Gynecol, of British Empire, p. 269. 1907. 
Pradella: Inaug.-Dissert., Zinich, 1906. 

Piielander and Mayer: Arcliiv f. Gynakologie. Band S7, Heft 1. 1909. 
Rinimin: Monatssch. f. Geburtsliiilfe u. Gynakol.. Bd. 25. Heft 2, 1907. 
Rissmann: Medicin. Ivlinik, p. 350. 1907. 

Rosthorn: Monatssch. f. Geburtsliiilfe u. Gynakol.. Bd. 23, Heft 5. 1906. 
Sclimidt: Deutsche m. AVochenschrift, Xo. 24, 1909. 
Tuszkai: AYiener med. AYochens.. a'oI. 57, p. 1330. 1907. 
von Herff : Monatssch. f. Geburtsliiilfe u. Gynakol.. Bd. 24. Heft 6. 1907: 

Miinchener m. AYochen., Xo. 50, 1908; and Beitrage f. Geburts- 

hiilfe u. Gynakol., Band 13, 1909. 
Williams: Surgery. Gynecology, and Obstetrics. September. 1906. 
Williamson: Journal of Obstetrics and Gynecology of the British 

Empire, March, 1906. 



RAPID AND FOKCIBLE DILATION OF THE WOMB 89 

RAPID AND FORCIBLE DILATION OF THE WOMB 

In direct contrast with the inchiction of labor, when we endeavor 
to follow Nature's methods in gradually softening and dilating the 
womb, is the rapid and more or less forcible dilation of the cervix. 
This is widely known by the appropriate term accouchemc^nt force. 

Among the many dilators which have been used for this purpose 
the solid dilator is safest, but is not of sufficient size to open the 
womb sufficiently for delivery. Dilators with two blades are open 
to the same objection, and have the further disadvantage that they 
make pressure laterally where the blood-vessels enter the uterus, 
and that lacerations made by these instruments may be accompanied 
by severe hemorrhage. Dilators with numerous blades are less ob- 
jectionable, as exerting pressure more equably upon the cervix. 

Among bladed dilators in use at present Bossi's is most import- 
ant and useful. The merits of this instrument are its length, its 
pelvic curve, the force which can be exerted by it, and its very grad- 
ual action, if used with caution. 

Its disadvantages are the fact that the unaccustomed operator 
has little or no idea of the force exerted, and that severe and fatal 
lacerations may follow its use in any but the most careful hands. 
When brought to the full extent of its dilating power, it opens the 
cervix widely enough to permit the passage of a full-term head. Such 
dilation is exceedingly dangerous and should be avoided. When 
used up to the middle of its scale, or 6 cm., in skilful hands, it is not 
dangerous, and often serves a most useful purpose. In using the in- 
strument the operator should consume at least from thirty to forty- 
five minutes in bringing the scale up to 6 cm. Pressure should be 
gradually exerted upon the cervix, and frequent examination should 
be made by the finger to determine that the dilator is in the proper 
position and that it is not causing severe laceration. If the latter 
occurs, there will be a trickling discharge of bright blood. Care should 
be taken to keep the instrument in the axis of the pelvis, w^hich makes 
the liability to extensive tear least. As soon as possible during 



90 OPERATIVE OBSTETRICS 

dilation the guards should be sUpped over the tips, making the 
danger of laceration considerably less. 

Newell's dilator is smaller than Bossi's, shorter, and has the 
merit of depending entirely upon the power of the hand for its dilating 
force. It is often useful in securing partial dilation, and is much 
better than the ordinary two-bladed dilator. 

Rapid dilation of the cervix under favorable conditions can be 
efficiently done by the fingers and hands. Harris's method, w^hich con- 
sists in introducing the fingers in increasing numbers into the uterus 
and sweeping them around the cervix, may be employed, but whatever 
method be followed the operator must be careful not to push his hand 
in cone shape through the cervix; in so doing there is danger of lacer- 
ating the womb in the lower uterine segment. If two fingers of each 
hand turned in opposite directions can be hooked within the cervix 
and rotated in opposite directions, pulling gentty downward and for- 
ward, the cervix will be dilated sufficiently without danger of ruptur- 
ing the uterus. When the fingers can be introduced into the body of 
the uterus and closed, the thigh can often be grasped and the body of 
the fetus brought into the cervix. If it is necessary to introduce the 
entire hand, the cervix should be dilated as wideh^ as possible, the 
hand folded as narrowly as it can be, and passed into the womb at the 
side of the promontoiy of the sacrum. The danger of rupturing the 
uterus will thus be less. 

Elastic bags are too slow in their action to cause rapid dila- 
tion of the cervix. The attempt to secure this result with bags is 
often followed by the bursting of a bag and the escape of its contents 
partially within the womb. As none but aseptic fluid is to fill these 
bags, but little harm is done. Air, however, might thus be intro- 
duced, and the accident is an annoying one. 

Where the cervix is unusually resisting, friable, and likely to tear 
extensively, it may be rapidly opened by multiple incisions. These 
should be made with blunt-pointed scissors in the four quadrants of 
the cervical ring, avoiding its two lateral portions. These cuts may 
extend nearly to the vaginal junction, and may be supplemented, if 



RAPID AND FORCIBLE DILATION OF THE WOMB 91 

necessary, by the use of an elastic bag, or by cautious dilation with 
the fingers. The method by incision is safer than the forcible dila- 
tion of the unaltered cervix by metal dilators or by the finger and 
hand; it is, however, not necessary where the cervix is softened and 
partially obliterated. 

Among the minor operations of obstetric surgery, none may be 
more trying than the rapid dilation of the cervix. Where the cer- 
vix in a primiparous patient is not softened, not shortened, and 
rigid, it should not be dilated. DeHvery in such a case must be effected, 
if necessary, by incision, vaginal or abdominal. The attempt to for- 
cibly and rapidly dilate such a cervix will surely terminate in disaster. 

The attempt to soften the unchanged cervix by hot vaginal douches 
or by the application of drugs is so uncertain, tedious, and inefficient 
that it has been discarded by expert obstetricians in favor of opera- 
tion. Repeated hot vaginal douches, the placing against the cervix 
of wedges of cotton soaked in chloral solution or smeared with bella- 
donna ointment, and the injection of cocain into the cervix have not 
given satisfactory results. 

Should laceration occur during forcible dilation of the cervix, 
the operator should empty the uterus with the least possible danger 
to the mother. After delivery the laceration should be thoroughly 
examined, under anesthesia, to determine whether it has opened into 
the pelvic or peritoneal cavity. Unless it be unusually extensive 
and accompanied by vigorous hemorrhage, it may be successfully 
treated by packing with 10 per cent, iodoform gauze. The body of 
the womb should first be packed with gauze, the end of which is 
drawn out through the vagina. A separate strip should then be 
introduced through the laceration, so that the end projects for a 
considerable distance from the pelvic or peritoneal cavity. This 
packing should be moderately tight and should be kept separate 
from the uterine packing. The vagina should then be tamponed 
with bichlorid gauze. Strychnin and ergot shoukl be given to main- 
tain uterine contraction. The uterine packing should first be removed 
in forty-eight hours, the uterus irrigated with lysol (1 per cent.), the 



92 OPERATIVE OBSTETRICS 

vagina should be thoroughly sponged out with bichlorid solution 
(1 :4000), the gauze packing in the laceration may then be removed 
and a new one inseited, using as little force as possible in its adjust- 
ment. This may remain foity-eight hours, when, in most cases, no 
further tampon is necessary. If the uterus be kept tightly con- 
tracted and a sterile \Tilvar dressing be used, such patients usuall}- 
make a good recovery. 

Tears of the cervix occurring during rapid dilation should be 
closed, if possible, as soon as the uterus is emptied. Tears extending 
into the A'ulva or peritoneal cavity are so high in the birth-canal that 
they cannot be efhciently reached from below and, hence, must be 
treated by tampon. 

Bibliography 

Bar: L'Obstetrique, Xo. 9, 1909. 

Bardeleben: Zentralblatt f. Gynakologie. Xo. 15. 1905. 

Bonnaire: La Presse med., Xos= 66 and 67. 1909. 

Bossi: Proceedings 16th International Congress, Budapest, 1909; also 

Gyn. Rundschau, Xo. 23, 1909. 
Bumi: Zentralblatt f. Gynakologie, Xo. 30, 190S. 
Biirger: Zentralblatt f. Gynakologie, Xo. 19, 1905. 
Contiguera: Miinchener med. Woe hens., p. 2297, 1907. 
Davis: Journal of Obstetrics and Gynecology, p. 502, 1907. 
Edgar: Transactions of xlmerican Gynecological Society. 1908. 
Eisenstein: Orvosi Hetilap, Xo. 27, 1907. 
Frey: American Journal of Obstetrics. February, 1909. 
Gauss: Proceedings 16th International Congress, Budapest. 1909. 
Gheorghiu: Zentralblatt f. Gynakologie, Xo. 42, 1907. 
Graemiger: Inaug.-Dissert., Zurich, 1906. 
Grone: Svenska Lakaitidningen, Xos. 35 and 36. 1907. 
Guasoni: Zentralblatt f. Gj'nakologie, Xo. 5, 1907. 
HaincU: Inaug.-Dissert, Erlangen, 1906. 
Jardine: British Medical Journal, July and August 24. 1907. 
Jung: Deutsche, med. Wochens.. Xo. S, 1907. 
Keyserlingk: Zentralblatt f. Gynakologie, Xo. 24, 1907. 
Klein: Deutsche, med. Wochens., p. 262, 1907. 
Knapp: Surgery, Gynecology, and Obstetrics, September. 1906. 
Leicester: Jour, of Obstet. and Gynecol, of British Empire, March. 1907. 
Leopold: Monatsschrift f. Geburts. und Gynakol.. Bd. 22. H. 1. 1905. 



OTEKATION KOK AIM'KNDICITIS 93 

Lewis: Jour, of Obstet. and (Jynecol. of J^ritish l^^mpire, p. 2G5, 1907. 
Licliteiisteiii: Arcliiv f. CJyiiiikologic, J^iUid 75, Heft 3, 1905; Zentml- 

blatt f. Ciynakologie, No. 14, 1905. 
Miiller: Zentralblatt f. Oynakologie, p. 320, 1907. 
Pfannenstiel : Miinclieiier ni. A\'oclieiis('lirift, Tso. 19, 1909; also Monats- 

sclirift f. Geburtshulfe iind Clynakologie, Bd. 30, p. 630, 1909. 
Schwabe: Inaiig. -Dissert., Jena, 1906. 

Sinclair: Jour, of Obstet. and Gynecol, of British Empire, Sept., 1905. 
Somers: Western Medical Review, Omaha, 1909. 
Weber: Archiv f. Gyniikologie, Band 82, 1907. 
Wendell: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 29, 

Heft 6, 1907. 
Winter: Proceedings 16th International Congress, Budapest, 1909. 

OPERATION FOR APPENDICITIS 

The frequent occurrence of appendicitis during pregnancy and the 
necessity for operation makes it necessary for the obstetrician to be 
famihar with the conditions which may be found in these cases. Peri- 
typhlitis in pregnancy is not uncommon. The chronic constipation 
of pregnancy favors the development of bacteria in the intestinal 
canal and explains the frequent occurrence of perityphlitis and 
appendicitis. The course of appendicitis in pregnancy will depend 
upon the period of gestation in which the condition arises. The 
anatomic peculiarities of the individual have an important part 
to play in determining the position of the appendix. Futh^ endeav- 
ored, by taking casts of the abdominal organs in 7 pregnant women, to 
determine the position of the cecum and appendix. He found that 
this differed in each patient. In 100 cases Treves found the cecum 
and appendix under the Hver in 18. Terenetzki in 65 bodies found 
the cecum higher than usual in one-third. In 200 subjects Schrefer- 
decker found the cecum lower than normal in all but 2. Four loca- 
tions of the cecum and appendix in pregnancy may be recognized as 
practically normal: First, near the crest of the ihum. Second, in 
the fossa of the ilium near the anteroposterior spine. Third, on the 
iliopectineal line. Fourth, near the umbilicus. I have seen during 
pregnancy, at about the third month, the appendix adherent to the 
1 Archiv f. Gyn., Band 76, Heft 3, 1905. 



94 OPERATIVE OBSTETRICS 

fundus uteri. It is probable that the growing uterus displaces the 
cecum at about the fourth month. The appendix is carried upward 
into the abdomen and this location makes inflammation of the cecum 
and appendix more than usually dangerous. After labor the cecum 
resumes its usual level, but if the appendix is adherent to the pelvic 
organs it accompanies them into the pelvis during involution. 

The earlier the pregnancy the less dangerous is appendicitis. As 
pregnancy proceeds, the tendency is for infection to spread from the 
appendix to the surrounding tissues, and for adhesions to occur be- 
tween the uterus and surrounding organs, so that a mass gradually 
forms, in which the appendix is the focus. Should the disease go ta 
abscess formation, the inner wall of the abscess-cavity will be the 
uterus. Should the uterus discharge its contents prematurely, uter- 
ine contractions may burst the abscess wall, allowing infected material 
to escape into the peritoneal cavity. In cases where suppuration de- 
velops gradually, its tendency may be to extend toward Douglas^ 
pouch, and if neglected, to open through this pouch into the vagina., 
or, possibly, into the bowel. This is a favorable termination, and is 
one of the methods by which spontaneous recovery may occur. 
Before the fourth month the uterus fills the pelvis so completely that, 
it is difficult for a considerable quantity of pus to find room in the^ 
pelvis. 

As appendicitis is more dangerous as pregnancy proceeds, early- 
operation is especially indicated. Even in mild cases the safer method 
requires the removal of the appendix in the absence of peritonitis^ 
and acute infection. The tissues should be subjected to the least, 
possible disturbance, and in cases where the appendix is not ruptured 
drainage should not be used. Opium should be given for several days, 
after the operation to prevent the premature emptying of the uterus. 

In the later months of pregnancy, in chronic appendicitis, if there 
has been much fever, with or without chills, the obstetrician must sus- 
pect circumscribed abscess. Incision should be made over the point 
of greatest tenderness, the pus evacuated, with drainage, without 
disturbing the surrounding tissue. A cautious effort should be made- 



OPEllATION FOR APPENDKITIS 95 

to find the appendix and, if possible, to remove it. If it cannot 
readily be removed, it should be laid freely open and allowed to 
slough away with the wall of the abscess. Free drainage with a soft- 
rubber tube, substituted later by strands of gauze, is indicated. The 
patient should be placed in Fowler's position and Murphy's instil- 
lation of saline fluid should be employed. Uterine contractions 
should be prevented, if possible, by the administration of opium. 

Should pregnancy be interrupted after operation for appendi- 
citis, the uterus should be emptied with the least possible manipu- 
lation. As septic infection may extend to the uterus, its cavity 
should be packed and drained with iodoform gauze (10 per cent.) for 
forty-eight hours after delivery. Should peritonitis develop, the 
abdomen should be opened sufficiently for a thorough exam- 
ination, drains inserted in the most dependent portions, and salt 
solution freely used with stimulation. 

It is difficult to give a mortality rate for appendicitis compli- 
cating pregnancy. The earlier the case is seen and the more promptly 
the appendix is removed, the better for the patient. The later the 
period of gestation in which appendicitis develops the greater the 
danger. Good judgment on the part of the operator in avoiding 
unnecessary manipulation will do much in lessening the mortality 
in severe cases. 

Bibliography 

Brindeau and Jeannin: Bull, de la See. d'Obstet. de Paris, No. 4, 1909.. 
Calmarm: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 26^ 

Heft 4, 1907; Munchener med. Wochens., No. 9, p. 441, 1907. 
Coe: Surgery, Gynecology, and Obstetrics, July, 1905. 
Croste: Thesis, Paris, 1906. 
Cuff: British Medical Journal, July 4, 1908. 
Davis: American Journal of Obstetrics, March, 1906. 
Dupuys: Thesis, Lille, 1906. 

Findley: American Journal of Obstetrics, December, 1909. 
Fromm: Zentralblatt f. Gynakologie, No. 18, 1908. 
Fiith: Archiv f. Gynakologie, Band 76, Heft 3, 1905. 
Halban: Wiener Klin. Wochens., No. 47, 1909. 
Hilton: Surgery, Gynecology, and Obstetrics, October, 1907. 



96 opeeati^t: obstetrics 

Hirschberg: Archiv f. Gynakologie, Band 74. Heft 3. 1905. 

Ivlein : ^lonatsschrift f . Geburtshiilfe imd G^Tiakologie. Band 24, Heft 5, 

1906. 
Kiimmel: Miinchener med. Wochens.. Xo. 21. p. 1059. 1907. 
Lindner: Archiv f. Gynakologie. Band S2. p. 17. 1907. 
Lobenstine: Bulletin of the L^ing-In Hospital. Xew York. September, 

190S. 
Lockyer: Internat. Clinic, vol. 2. p. 177, 1907. 
Mansfeld: Report of G^^Tiecological Section of Association of Physicians 

at Budapest, p. 191, 1909. 
Offergeld: Archiv f. G^Tiakologie. Band S9. Heft 1, 1909. 
Pinard: Annal. des. G^ti., p. 357, 1900, 
Prof ant er: Wiener klin, Wochenschrift, Xo. 11. 1909, 
RenvaU: British Medical Journal. January- 2. 1909. 
Rodgers: Journal of American Medical Association, vol. -19. p. 2006, 

1907. 
Rumely: Inaug.-Dissen., Freibm-g. 1906. 
Runge: BerHner Khn. Wochenschrift, Xo, 27, 1907. 
Stabler: Monatsschiift f. G^btutshiilfe und G^Tiakologie, Band 26. 

Heft 2. 1907: Zentralblatt. f. Gynakologie. Xo. 50, 1909. 
Tissier and Lemeland: Zentralblatt f. G^-nakologie. Band 30. p. 533, 

lfM37. 
Yineberg: Xew York Medical Journal. Band S5, p. SSO, 1907. 
von FeUenberg: Monatsschiift f. Gebmtshidfe tmd GAmakologie. Band 

25. p. 7S0, 1907, 
von Rosthorn: Med. Ivhnik. Band 3, p. 339. 1907. 
Weber: Deutsche Zeitschrift f. Clur.. Band 93. Heft 3. 1907. 



CHOLECYSTOTOMY IN PREGNANCY 

As abscess of the appendix may reciiure operation during preg- 
nancy, so infection of the gall-bladder may caU. for incision and 
drainage. The s^Tnptoms of cholecystotom}- compHcating preg- 
nancy are those iisuaUy obser\'ed. The growing distention of the 
transver.se colon, so often seen in pregnant women, may obscure 
somewhat the diagnosis and make examination of the gaU-bladder 
difficult. As pregnancy advances the abdominal viscera are 
pushed upward, and the gall-bladder is imdoubtedly somewhat 
higher than in the non-pregnant and may be more difficult of access. 
In these cases efforts should be made to thoroughly empty the 



OPERATIONS UroX THK KIDXKVS DUHIXG PKEGXANCY 97 

intot^tines of solid, liciuid, and gaseous contents before a positive 
diagnosis is made or operation untlertaken. 

Cholecystotoniy in pregnancy differs in no essential way from 
the operation in the non-pregnant. The tendency of pregnant 
women to toxemia makes the occurrence of hemorrhage after opera- 
tion more likely than usual, and the hemorrhage may be more pro- 
fuse and dangerous. The interruption of pregnane}' should be 
prevented if possible. If these dangers can be avoided the opera- 
tion should give good results in pregnant women. After the opera- 
tion every effort should be made to avoid acetonemia, as the over- 
buixlened condition of the liver in pregnancy would especially favor 
such an occurrence after prolonged anesthesia. 

BlBLIOGRAPHY 

Acconclii: Annali di Ostetricia. Xo. 3, 1906. 

Andrews and Blacker: Journal of Obstetrics and Gynecolog}' of the 

British Empire. November. 190S. 
Brook: British Medical Journal. June 16, 1906. 
Calderini: Annal. des Gyn.. Second Series, vol. 4. p. 42S. 1907. 
Christiani: Zentralblatt f. Gynakologie. Xo. 15. 1905. 
Cuff: British Medical Journal. July 4. 190S. 

Dax-is: Bulletin of the Lying-in Hospital. X'ew York. June. 1905. 
Kiihn: Frauenanz. Heft 10. p. 434. 1909. 

Leicester: Jour, of Obstet. and Gynecol, of British Empire. April. 1905. 
Peterson: Trans. Amer. Gyn. Soc. 1910. 
Poncet: Gazette des. Hop., vol. 79. May 31. 1907. 
Rissmann: Zentralblatt f. Gynakologie. X'o. 20, 1909. 
Roith: Monatsschrift f. Gebiutshiilfe und Gynakologie. Band 29. Heft 4, 

1909. 
Ross: American Journal of Obstetrics. April. 1909. 
Sehoenborn: Monatssch. f. Gebmts.und GynakoL. Bd. 29. Heft 1. 1909. 
Thevenot: Revue de Chir.. September. 1906. 

OPERATIONS UPON THE KIDNEYS DURING PREGNANCY 

Pyehtis from infection by the Bacillus coH communis is not 
uncommon during pregnancy. Foitunately for the patient it usu- 
ally runs a comj^aratively mild course, and very seldom requires 



yo OPERATIVE OBSTETRICS 

surgical treatment. Should surgical kidney develop, nephrotomy 
or nephiTctomy would be indicated, as in other cases. 

In eclampsia, Edebohls urged and practised decapsulation of 
the kidneys. His operation consisted in exposing the kidney, in- 
cising its capsule along the convex border, and allowing the kidney 
substance to escape. This operation has been performed by others^ 
and in some cases the function of the kidneys has been resumed 
and patients have apparently improved. Edebohls urged its per- 
formance in threatened eclampsia, where other methods to secure 
ehmination had failed, in the presence of eclampsia where other 
methods had caused no improvement, in cases of nephritis not 
advanced, and in interstitial changes where kidney failure seemed 
imminent through engorgement. The operation has not been per- 
formed sufficiently often to give an accurate judgment as to its value. 
It is justifiable for the conditions described. In these the opera- 
tion is without mortality, while it is difficult to estimate its mor- 
bidity. 

Bibliography 

Adrian: Deutsche med. Wochens., Band 33, p. 2024, 1907. 

Balloch: Surgery, Gj^necology, and Obstetrics, March, 1908. 

Barth: Deutsche med. Zeitschrift f. Chir., Band 85, 1907; Monatsschrift 

f. Geburtshiilfe mid Gynakologie, Band 26, Heft 5, 1907. 
Cragin: Surger}', Gynecolog}', and Obstetrics, Ma}^, 1906. 
Cumston: American Journal of the Medical Sciences, July, 1908. 
Falgowski: Zentralblatt f. Gynakologie, Xo. 2, 1908. 
Ferguson: Journal of Obstetrics and Gynecology of the British Empire^ 

March, 1907. 
Frank: Miinchener med. Wochens., Xo. 51, p. 2471, 1907. 
French: British Medical Journal, May 2, 1908. 
Funck-Brentano : Ann. cle Gyn. et Obstet., April, 1909. 
Gauss: Zentralblatt f. GjmakoL, Xo. 19, p. 521, 1907, and Xo. 19, 1908. 
Germain: La Ginecologie, July, 1909. 
Hicks: British Medical Journal, vol. i, p. 203, 1909. 
Kalmanowitsch : Gyn. Helvet. Friihjahrsausgabe, p. 187, 1909. 
Kleinertz: Zentralblatt f. Gynakologie, Xo. 26, 1908. 
Milligan: Jour, of Obstet. and Gynecol, of British Empire, Feb., 1906» 
Mirabeau: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 26^ 

Heft 6, 1907; Archiv f. Gynakologie, Band 82, 1907. 



ABDOMINAL SECTION DUUINCJ TliEGNANCY 99 

Newell: Boston Medical and Surgical Journal, vol. 156, p. 241, 1907. 
Picri: Annal. de Clyn. et d'Obstet., vol. 4, Series 2, p. 257, 1907. 
Pinard: Annal. de Gj-n. et d'Obstet., April, 1906. 
Polano: Zentralblatt f. Clyniikologie, No. 1, p. 13, 1907, and No. 1, p. 

14, 190S. 
Puech: Bull, de la Soc. d'Obst. de Paris, Nov., 1909; also No. 5, p. 233, 

1909. 
Schumacher: Inaug. -Dissert., Bonn, 1905. 
Sippel: Zentralblatt f. Gynakologie, No. 37, 1905, and No. 51, p. 1586, 

1907; Miinchener med. Wochens., No. 44, p. 2173, 1908; Berliner 

klin. Wochens., No. 49, p. 1559, 1908. 
Smith: Jour, of Obstet. and Gynecology of British Empire, Aug., 1905. 
Sondern: Bulletin Lying-in Hospital, New York, No. 1, 1909. 
Stoeckel: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 28, 

Heft 5, 1908; Zeitschrift Gyn. Urol., Heft 1, Band 1, 1908. 
Vineberg: American Journal of Obstetrics, June, 1908. 
von Herff: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 24, 

Heft 6, 1906. 

ABDOMINAL SECTION DURING PREGNANCY 
The presence of tumors in the abdomen, the occurrence of gun- 
shot or incised wounds, rupture of the abdominal viscera by accident, 
intussusception, rapid growth of malignant disease attacking the 
intestines, development of tubercular peritonitis and other con- 
ditions may call for abdominal section during pregnancy. An 
enlarged dislocated spleen has been successfully removed without 
the disturbance of gestation. Abdominal section during pregnancy 
may be undertaken with fair prospect of success, in spite of the 
existence of pregnancy. The operator must disturb the tissues as 
little as possible to avoid the interruption of gestation. If the 
fetus be viable and the mother's condition critical, it may be justi- 
fiable to include in the abdominal section the emptying of the uterus 
by uterine section. This avoids the risks occasioned by uterine 
contraction when the uterus expels its contents prematurely after 
abdominal section, and enables the operator to see accurately what 
the intra-abdominal conditions will be after the uterus is emptied. 
It also gives the child the best chance for life; the removal of the 
child by uterine incision can be done so quickly and with so little 



100 OPERATIVE OBSTETRICS 

shock to the mother that it would not mihtate against her in any 
compKcated case. The increased vascularit}^ of the abdominal 
tissues, especial]}' in the neighborhood of the uterus, may cause 
embarrassing hemorrhage. Fluid may also be found in the abdom- 
inal cavity as the result of pressure by the growing womb. 

Bibliography 

Ghevannaz: Jour, de med. de Bordeaux, vol. 37, p. 101, 1907. 
Connel-Scheffield : Journal of Obstetrics and Gynecology of the British 

Empire, vol. 10, No. 2, 1907. 
Meek: British Medical Journal, vol. 1, p. 928, 1907. 
Neu: Archiv f. Gynakologie, Band 80, Heft 2, 1906. 
Pfannenstiel : American Journal of Obstetrics, August, 1908. 
Reynolds : American Journal of Obstetrics, August, 1908. 
Schauta: Zentralblatt f. Gynakologie, No. 14, 1908. 
Tixier: Lyon Med., No. 40, 1906. 
Zachen: Inaug. -Dissert., Leipsic, 1907. 

OPERATION FOR ECTOPIC GESTATION 

By ectopic gestation we now understand the development of the 
embryonic ovum outside the cavity of the womb. 

This may occur in the uterine wall at its cornu, in the Fallopian 
tube, in the ovary, and in the pelvic or abdominal cavity. The 
extent to which the development of the embryonic ovum will pro- 
ceed must depend upon the site of its attempt to develop. Thus, 
in the uterine cornu, chorionic tissue will make its way through the 
uterus, causing rupture of the uterine muscle and hemorrhage. In 
the Fallopian tube, the envelope of the embryo must rupture after 
a few months' gestation. In the ovary its rupture must occur very 
early, for ovarian pregnancies have not been found far advanced. 
When the embryonic ovum remains in the abdominal cavity, if 
planted upon suitable material, it may grow very nearly to full 
term. 

A few years ago there seemed no question but that the presence 
of an ectopic gestation demanded operation as soon as the diag- 
nosis was made. Those who urged this view cited the dangers of 



Ol'EHATlOX FOU ECTOPR' CESTATIOX 



101 



liemorrhage and shock as sufficient reason for immediate oi)era- 
tion. Champneys' observations u})on liosi)ital patients who were 
kept in bed under observation, but without operation, showed that 
a very considerable proportion of cases of cn-topic gestation, ru])- 
tured and unruptured, nH'cn-ennl without interferences These 
patients did not regain tht^ir accustomed health as soon as did those 




Fig. 23. — Tubal pregnancy (isthmic), unruptured: F, Fimbriated extremity; 
I', uterine extremity of tube; O, ovarj^; I, tube cut, showing gravid sac in isthmic 
portion. (Ladinski, in American Journal of Obstetrics.) 



subjected to operation, but they did not die from hemorrhage or 
shock. Robb's recent paper before the American Gynecological 
Society Transactions, \'ol. 32. 1907, describes experiments upon ani- 
mals in which the pelvic blood-vessels were severed, with the recoveiy 
of the animals from profuse hemorrhage. The clinical experience of 
obstetricians embraces cases where it seems as if immediate opera- 
tion turns the tide, through shock, against the patient. In America, 



102 



OPERATIVE OBSTETRICS 




Fig. 24. — Tubal pregnancy (infundibular), unruptured. Tube cut through: F, 
Fimbriated extremity; U, uterine extremity; O, ovary. (Ladinski, in American 
Journal of Obstetrics.) 




Fig. 25. — Same specimen as Fig. 24. Tube intact. (Ladinski, in American Journal 

of Obstetrics.) 



especially, as well as in Europe, the discussion has again arisen as 
to whether all cases of ectopic gestation should be subjected to 
immediate operation. 



OrERATIOX FOR ECTOPIC GESTATION 



103 



It is recognized that all cases of ectopic <>;(\statioii recover more 
completely aiitl permanently if subject(Hl at some time to opera- 
tion. The majority of opinion in the American Gynecological 
Society ^ was as follows : 

The judgment of the individual operator must (h^cide between 
immediate and deferred operation in each case. Obviously, with- 
out adequate assistance and appliances for asepsis operation should 
not be undertaken. Few operators, however, would go to such a 
case without the necessary assistance and appliances for operation. 




Fig. 26. — Uterine cast. (Ladinski, in 
American Journal of Obstetrics.) 



Fig. 27. — Uterine cast. (Ladinski, in 
American Journal of Obstetrics.) 



As obstetric surgery advances we are able more and more to control 
the patient's environment. 

Preparations should be made for operation in all cases of rup- 
tured ectopic gestation. If the patient is shocked, but shows a 
tendency to improve, the pulse slowly regaining and the nervous 
system acquiring a better tone, although prepared to operate, the 
operator should wait, if possible, until the patient is in fair condi- 
tion for operation. If, when preparations for operation have been 

1 Transactions, vol. 33, 1908. 



104 



OPERATIVE OBSTETRICS 



completed, she shows no sign of improvement, but is growing steadily 
worse, operation is the patient's only hope. 




R 

Fig. 28. — Simultaneous tubal aboition and rupture: U. Uterine extremity: 
F, fimbriated extremity; O. ovaiy*: R. rupture in tube wall: C. coagulum expelled 
from ostium abdominale. ^^Ladinski. in American Journal of Obstetrics.) 




Fig. 29.— Threatened tubal abortion with slight bleeding from fimbriated 
extremity: U, Uteiine extremity of tube: F, fimbriated extremity: O. ovaiy. 
(Ladinski, in American Journal of Obstetrics.) 



Transfer to hospital is sometimes dangerous in these cases because 
moving the patient may loosen a blood-clot in the abdomen and set 



OrEKATIOX von ECTOPIC (IKSTATION 



105 



up fresh hemorrhage. On the contrary, hospital faciUties are so 
superior that if transportation can be eftectal with gentleness and 




Fig. 30. — Complete tubal abortion: U, Uterine extremity: F. fimbriated ex- 
tremity; T, tube cut, showing engorged mucosa. ^^Ladinski, in American Journal 
of Obstetrics.) 




Fig. 31. — Incomplete tubal abortion ^\-ith fetus about to escape into peritoneal 
cavity, also showing thinning and distention of tube wall: V, Uterine extremity: 
P, distended tube wall cut. showing placenta: F, fetus protruding from ostium 
abdominale. i Ladinski. in American Journal of Obstetrics.) 



rapidity, the ])atient's surroundings at home l^eing unfavorable, 
it should ceiiainlv be done. In no branch of obstetric sur^'erv is 



106 



OPERATIVE OBSTETRICS 



better judgment demanded, and in no cases are the life-saving effects 
of operation so clearly demonstrated. 

Operation in ruptured ectopic gestation should be as simple 
as possible: incision, the finding of the point of rupture, securing 
the ruptured and bleeding viscus. and the rapid closure of the ab- 
domen are the essentials. AVhile the obstetrician's instinct would 
lead him to empty the abdominal or pelvic cavity of blood-clot, it 




Fig. 32. — Incomplete tubal abortion, -u-ith fetus in abdominal ca\ity: U. Uterine 
extremity of tube: F, ostium abdominale patulous: P. placenta. i^Ladinski, in 
American Journal of Obstetrics.) 



may be safer to allow it to remain. Its presence favors infection, 
but its complete removal would take time, exposing the patient to 
added shock, and would deprive her of something which might be 
absorbed to some advantage. In desperate cases the arm should 

be prepared and intravenous saUne transfusion done by an assist- 
ant Avhile the operator opens the abdomen. 

In unruptured ectopic gestation the obstetrician should avoid 
examinations conducted with considerable force, lest the envelope 



OPERATION' FOR I<](T()I'I(' TESTATION 



107 



of the embryo be rupturcHl. Operation slioiild b(^ undertaken as 
soon as the (Iia,a;n()sis is made if the eireumstances surroLUKhng the 
patient are favorable. 



-*. i^ 




^-^^/^.^^ 






Fig. 33. — Tubal abortion terminating in mole, still present in tube: U, Uterine 
extremity of tube; F, fimbriated extremity of tube; O, ovaiy; M, mole in tube. 
(Ladinski, in American Journal of Obstetrics.) 





Fig. 34. — Tubal abortion terminating in mole, ^ith mole discharged into peri- 
toneal cavity: U, Fterine extremity of tube; F, fimbriated extremity of tube; 
O, ovary; M, mole in peritoneal cavity. (Ladinski, in American Journal of Ob- 
stetrics.) 

In ectopic gestation which has ruptured some time before the 
patient comes under observation, conservative procedures will 



108 



OPERATIVE OBSTETRICS 



usually be most successful. If the pelvis contains a large hema- 
tocele it may be opened through the posterior vaginal vault, clot 




Fig. 35. — Ruptured tubal pregnancy (verj^ early isthmic): U, Uterine extremity 
of tube; I, ruptured isthmic portion of tube; F, fimbriated extremity of tube; O, 
ovary; C, corpus luteum of pregnancy discharged from oyary. (Ladinski, in Ameri- 
can Journal of Obstetrics.) 

evacuated, and the cavity drained. In abdominal pregnancy the 
fetus and the cord should be removed, the cord hgated close to 




Fig. 36. — Ruptured tubal pregnancy (isthmic): U, Uterine extremity of tube; 
F, fimbriated extremity; R, ruptured isthmic portion of tube. (Ladinski, in Ameri- 
can Journal of Obstetrics.) 

the placenta, the cavity occupied by the fetus tamponed with gauze, 
and the placenta allowed to come away gradually. Under only 



OrEHATIOX FUK ECTUl'lC CJESTATIOX 109 

exceptional circuiiistanees can a full-formed placenta be removed 
in ectopic ge^^tation without a t^evere and dangerous hemorrhage. 
In cornual pregnancy the uterine cornu should be excised and the 
tube on that side removed. In tubal pregnancy the tube which 
contained the ovum should be removed, and in ovarian i)regnancy 
the ovary should be taken away. In the case of a lithopedion, 
patients sometimes display a curious reluctance to part with the 
fetus. Its envelope should not be disturbed if the patient finally 
consents to operation. 




Fig. 37. — Ruptured tubal pregnancy (infundibular) with very little hemorrhage: 
U, Uterine extremity of tube: F, fimbriated extremity of tube; O, ovaiy^; R, rupture 
in infundibular portion of tube. (Ladinski, in American Jomnal of Obstetrics.) 

In operating for ectopic gestation, unruptured or ruptured, 
some time before operation, the patient being in no immediate danger, 
the opportunity should be utilized to examine the uterine append- 
ages on the side opposite to the site of implantation. Diseased 
Fallopian tubes should be removed, and thus the patient spared 
possible danger of the recurrence of ectopic gestation. In bicorn- 
ate uterus ectopic gestation may be exactly simulated by pregnancy 
in one cornu. Should the uterus be rudimentary, a pregnant cornu 
will rupture as the fetus grows, and the patient be subjected to 



110 OPERATIVE OBSTETRICS 

the dangers usual in ectopic gestation. The cornu should be treated 
as the fetal sac and removed. The frequency of repeated ectopic 
gestation is estimated by Ham at 1 in 54; Wertheim, 7 to 8 re- 
peated cases in 120; Kiistner, 5 in 116; Diihrssen, 2 in 37; Ryser, 
4 in 50; Reifferscheid, 2 in 40; Orthmann, 2 in 45; Heikel, 4 in 80; 
Hermann, 5 in 125. Although these figures differ widety, they are 
the result of considerable experience, and show that repeated ectopia 
gestation is not uncommon. 




Fig. 38. — Tubal pregnancy with very large rent of tube: U, Uterine extremity 
of tube; F, fimbriated extremity of tube; O, ovary; R, rupture of tube wall; G, gesta- 
tion sac expelled into peritoneal cavity. (Ladinski, in American Journal of Ob- 
stetrics.) 

In cases where ectopic gestation has not proved immediately 
fatal, and suppuration has occurred in the mass surrounding the 
embryo, operation should consist in incision and drainage. Noth- 
ing more should be attempted until the cavity has grown as small 
as possible and nothing but a sinus remains. Such will usually 
close spontaneously with the simplest treatment; free motion on 
the part of the patient seems useful in bringing about such a closure. 
In dealing with obscure cases of irritation of the bladder and rectum, 
the obstetrician must not forget the possibility of ruptured suppu- 



OPERATION FOR ECTOPIC GKSTATIOX 



111 



rating ectopic pregnancy and its discharge into one of these vis- 
/?era. Fetal bones have made their way into the bladder and 




"^v. 




i-^-;;* 



Fig. 39. — Infundibular tubal pregnancy with rupture terminating in tubo- 
abdominal, with final rupture into peritoneal cavity: U, Uterine extremity of tube; 
F, fimbriated extremity of tube; O, ovary; P, placenta attached to intestines and 
omentum. (Ladinski, in American Journal of Obstetrics.) 




Fig. 40. — Torsion of tube with formation of tubal hematoma and hemorrhage 
into pelvic cavity: U, Uterine extremity of tube; F, fimbriated extremity of tube; 
T, twists of tube; C, cyst in infundibular portion of tube; H, hematoma of tube 
showing section removed for microscopic examination. (Ladinski, in American 
Journal of Obstetrics.) 



occasioned irritation, and fetal debris has been discharged into the 
rectum. Dilation of the urethra, followed bv the removal of the 



112 OPEKATIVE OBSTETRICS 

foreign bodies, caused a cystitis to disappear. It is usually best 
not to attempt to open up fistulous tracts in these cases, as they 
will close spontaneously if time be given. 

While we believe that all cases of ruptured ectopic gestation 
should not be subjected to operation as soon as they are seen, we 
must not forget that statistics abundantly show that a patient 
having ectopic gestation recovers more completely and satisfactorily 
under operation than by any other treatment. Operation, then, 
remains the only justifiable treatment for ectopic gestation. The 
exact time and circumstances under which it is to be apphed must 
be left to the judgment of the individual operator. 

Bibliography 
Adjeroff: Wiener klin. Wochens., No. 51, p. 615, 1907. 
Allwood: British Medical Journal, February 16, 1907. 
Andrews: Zentralblatt f. Gynakologie, No. 48, p. 1347, 1907. 
Arnold: Lancet, June 1, p. 1490, 1907. 
Audebert and Dieulafe: Annal. de Gyn. et d'Obstet., p. 472, August, 

1907. 
Baer: American Journal of Obstetrics, January, 1909. 
Barnsby: Review of Gynecological and Abdominal Surgery, June, 

1906. 
Barrozzi: La Gynec, No. 6, p. 489, 1907. 
Bell, Standage, and others: Discussion: Journal of Obstetrics and 

Gynecology of the British Empire, December, 1906. 
Boldt: American Journal of Obstetrics, May, 1909. 
Borszeky: Orvosi Hetilap, No. 3, 1907. 

Bovee: American Journal of Obstetrics, p. 509, October, 1907. 
Brindeau: Bulletin de la Soc. d'Obstet. de Paris, No. 9, p. 250, 1907. 
Bucura: Wiener klin. Wochens., No. 4, 1907. 
Chenot: La Gynec, p. 481, December, 1907. 
Child: American Journal of Obstetrics, January, 1907. 
Cohn: Revue de Gynecologic, No. 1, 1909. 
Costa: Annali di Ostetricia, vol. 1, p. 185, 1907. 
Croissier: Ann. de Gyn. et d'Obstet., p. 688, November, 1907. 
Discussion: American Gynecological Society, American Journal of 

Obstetrics, July, 1908. 
Doederlein: Zentralblatt f. Gynakologie, No. 11, p. 309, 1907. 
Doldow: Inaug. -Dissert., Jena, 1906. 
Doleris: La Ginecologia, November, 1909. 



OPEKATIOX FOR ECTOPIC CESTATION 113 

Donald: Journal of Obstetrics and (lynecology of the British Empire, 

vol. 2, Part 4, p. 305, I!)07. 
Eden: Transactions of the Obstetrical Society, London, vol. 43, Part 4, 

p. 272, 1907. 
Elvrescht: American Journal of Obstetrics, p. 662, November, 1907. 
Esch: Miinchener m. Wochenschrift, No. 32, 1909. 
Falk: Zentralblatt f. Gynakologie, No. 43, p. 1306, 1907, and No. 45, 

p. 1404, 1907. 
Finsterer: Zeitschrift f. Heilkunde, Band 28, 1909. 
Fitzgerald: Lancet, November 23, p. 145, 1907. 
Fleuront: Miinchener med. Wochens., No. 37, 1906. 
Ford: Surgery, Gynecology, and Obstetrics, July, 1906. 
Frank: American Journal of Obstetrics, February, 1909. 
Franz: Zentralblatt f. Gynakologie, No. 7, p. 218, 1907. 
Freund: Sanniil. klin. Vortrage, Heft 28, 1907. 
Filth: Zentralblatt f. Gynakologie, No. 43, 1905. 
Galabin: British Medical Journal, March 21, 1903. 
Goodall: British Medical Journal, June 2, 1906. 
Grone: Zentralblatt f. Gynakologie, No. 2, 1909. 
Grube: Zentralblntt f. Gynakologie, p. 345, November 12, 1907. 
Guerdjikoff: Ann. de Gyn. et d'Obstet., p. 585, October, 1907. 
Haagn: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 22, 

Heft 6, 1905. 
Hannes: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 21, 

Heft 3, 1905. 
Harte: British Medical Journal, January 25, 1902. 
Hayd : American Journal of Obstetrics, p. 657, November, 1907. 
Heim and Lederer: Monatsschrift f. Geburtshiilfe und Gynakologie, 

Heft 1 and 2, 1907, and Band 25, Heft 2, 1907. 
Henkel: Miinchener med. Wochens., No. 27, p. 1344, 1907. 
Herbert: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 63, Heft 

3, 1909. 
Hicks: British Medical Journal, February 8, 1908. 

Hoehne : Zeitschrift f. Geburtshiilfe u. Gynakologie, Bd. 63, Hft. 1, 1909. 
Hermann: Annalen d. Staclt. allgem. Krankenhaiiser zu Miinchen, 

Band 12, 1900 and 1902. 
Huggins: American Journal of Obstetrics, November, 1909. 
Immel: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 27, 

Heft 1, 1908. 
Iwasse: Archiv f. Gynakologie, Band 84, Heft 2, 1908. 
Jarzeff: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 28, 

Heft 2, 1908. 

8 



114 OPERATIVE OBSTETRICS 

Karczewskr: Medycyna, Polinsch., 1907. 

Kelley : American Journal of Obstetrics, p. 481, October, 1907. 

Kiippenheim: Arcliiv f. Gynakologie, Band 81, Heft 1, 1907. 

Landau: Berliner klin. AVochens., No. 32, 1906. 

Lassaud and Wertlieim: Zentralblatt f. Gynakologie, No. 9, p. 261, 

1907. 
Lehmann: Zentralblatt f. Gj^nakologie, Xo. 46, 1909. 
Leicester: Journal of Obstetrics and Gynecology of the British Empire, 

September, 1907. 
Leo: Zentralblatt f. Gynakologie, Xo. 36, 1909. 
Lichtenstein : Zentralblatt f. Gj'nakologie, Xo. 43, p. 1308, 1907. 
Limnell: Archiv f. Gynakologie, Band 81, Heft 2, 1907. 
Linclequist: Hygiea, August, 1907. 
Link: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 20, Heft 6, 

1904. 
Lovrich: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 27, 

Heft 6. 1908. 
Lyle: Journal of Obstetrics and Gynecology of the British Empire, 

December, 1906. 
MacLean: British Medical Journal, April 14, 1906. 
Mantel: Ann. de Gyn. et d'Obstet., vol. 34, p. 84, 1907. 
Maygrier: Bull, de la Soc. d'Obstet. de Paris, p. 234, Xos. 7 and 8, 1907. 
McCalla: Surger}^, Gj^necology, and Obstetrics, March, 1909. 
McDonnel: Australasian Medical Gazette, p. 287, June, 1907. 
Mirabeau: Zentralblatt f. Gynakologie, Xo. 49, 1905. 
Mond: Zentralblatt f. Gynakologie, Xo. 12, 1907. 
Neugebauer: Monatsschrift f. Geburtshiilfe und Gj'nakologie, Band 26, 

p. 849, 1907. 
Nowicki: Przeglad Lekarska, Xo. 7, 1907. 
Xj'-ulosi: British Medical Journal, p. 1570, Xovember 30, 1907. 
Oliver: Lancet, August 22, 1908. 
Orthmann: Zentralblatt f. Gynakologie. Xo. 49, pp. 1538 and 1542, 

1907. 
Phillips: Journal of Obstetrics and Gj^necology of the British Empire, 

January, 1907. 
Picard: These de Paris, 1908. 

Platen: Zentralblatt f. Gynakologie, Xo. 1, p. 26, 1907. 
Polak: Long Island MecUcal Journal, March, 1909. 
Piiismann: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 52, 

Heft 2, 1904. 
Puppel : Monatsschrift f . Geburtshiilfe und Gj^nakologie, Band 29, Heft 

3, 1909. 



OPERATION FOR ECTOl'K^ (I EST ATI ON 115 

Piirslow: l^ritisli ModicalJournal, April 17, 1909. 

HchmI: AnuM-icaii Journal of Obstetrics, I'ebruary, 19()G. 

Keifforsclieicl : Deutsche nied. Wochcns., No. 40, p. 1GG5, 1907. 

Hidont: Lancet, vol. 172, p. S()5, March 23, 1907. 

Rieck: Zentralbhitt f. Gynakologie, No. 12, p. 347, 1907; No. 30, 

p. 938, 1907; No. 35, p. 1049, 1907. 
Robb: American Journal of Obstetrics, July, 1907, and vol. 52, p. 6, 

1907. 
Roberts: Transactions of the Obstetrical Society of London, vol. 48, 

Part 4, p. 309, 1907. 
Rodiger: Zentralblatt f. Gynakologie, No. 31, 1906. 
Rutherford: Lancet, vol. 172, p. 881, March 30, 1907. 
Sazbo: Archiv f. Gynakologie, Band 82, 1907. 
Scheffzeck: Archiv f. Gynakologie, Band 83, Heft 2, 1907. 
Scheffzek: Archiv f. Gynakologie, Band 82, Heft 3, 1907. 
Schumacher: Inaug. -Dissert., Bonn, 1907. 
Seeligmann: Deutsche med. Wochens., No. 22, 1906; Zentralblatt f. 

G3'nakologie, No. 32, p. 985, 1907, and No. 12, p. 342, 1907. 
Simpson: Surgery, Gynecology, and Obstetrics, November, 1907. 
Sinclah': Journal of Obstetrics and Gynecology of the British Empire, 

April, 1907. 
Sittner: Archiv f. Gynakologie, Band 69, Heft 3, 1903; Deutsche med. 

Wochens., No. 30, 1906. 
Stark: British Medical Journal, p. 1232, May 25, 1907. 
Stillwagen: American Journal of Obstetrics, January, 1909. 
Stoddart: Surgery, Gynecology, and Obstetrics, October, 1908. 
Sturmdorf : Medical Record, January, 1909. 
Sudeck: Miinchener med. Wochens., No. 28, p. 1409, 1907. 
Sutter: Zentralblatt f. Gynakologie, No. 2, p. 62, 1907. 
Tantzscher: Zentralblatt f. Gynakologie, No. 27, 1908. 
Tate : Transactions of the Obstetrical Society of London, vol. 49, Part 1, 

p. 51, 1907. 
Tate, W. W. H. : Journal of Obstetrics and Gynecology of the British 

Empire, December, 1906. 
Toth: Journal of Gynecological Section of Association of Physicians, 

Budapest, p. 101, 1909. 
Valdagni : Journal of Obstetrics and Gynecology of the British Empire, 

June, 1905. 
Van der Linder et Goetzbuer: Jour, de Chir. et Ann. de la Soc. Beige. 

de Chir., p. 282, November, 1907. 
Van de Velde: Zentralblatt f. Gynakologie, No. 17, 1909. 
Vineberg: American Journal of Obstetrics, April, 1908. 



116 OPERATIVE OBSTETRICS 

Violet: La Ginecologia, No. 1, p. 63, 1909. 

Webster: American Journal of Obstetrics, vol. 56, p. 73, 1907. 

Weibel: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 22, 

Heft 6, 1905. 
Weinbrenner : Monatsschrift f . Geburtshiilfe und Gynakologie, Band 24, 

Heft 3, 1906. 
Weiss: Zentralblatt f. Gynakologie, No. 8, p. 251, 1907, and No. 8, 

1908. 
Weisswanger: Zentralblatt f. Gynakologie, No. 14, p. 383, 1907; Miinch- 

ener m. Wochenschrift, No. 8, 1909. 
Williams: Surgery, Gynecology, and Obstetrics, November, 1908. 
Windisch: Zentralblatt f. Gynakologie, No. 45, 1907. 



PART II 



THE SURGERY OF LABOR 

The Extraction of the Child Through the Vagina 

Indications. — The vaginal extraction of the fetus is safely pos- 
sible only when the pelvis is of sufficient size to permit a given fetus 




Fig. 41. — Head movable above the pelvic brim — the "floating head" (Bumm). 

to pass through its channel. The efl'ort at vaginal (extraction in 
highly contracted pelves is usually fatal and, should death not result, 
is followed by high morbidity. Before undertaking vaginal extrac- 

117 



118 



OPERATIVE OBSTETRICS 



tion the obstetrician must be sure that the pelvis is sufficiently 
large to permit the passage of the fetus. In the early months of 
pregnancy tliis question scarcely arises, but after the sixth month 
it may be determined. Pelvimetry should be practised in aU cases 
of vaginal dehvery, supplemented by palpation of the pelvis. Unless 
the conditions are favorable for such examination the patient should 
be anesthetized before it is undertaken. 




Fig. 42. — Head engaged in pelvic brim TBumm). 

The comparative size of mother and child should be ascertained 
by observing the presence or absence of engagement. This is the 
most valuable test which the obstetrician has concerning the rela- 
tive size of mother and child. Its recognition, then, is of primary 
importance in deciding upon vaginal dehvery. 

To determine the presence or absence of engagement, the bladder 
should be completely emptied by catheter; if the lower bowel con- 



THE EXTRACTION OF THE CHILD THROUGH THE VAGINA 



119 



tains an accuniiilation of feces, this should be removed. Unless 
the patient is a favorable subject for examination, she should 
be anesthetized with chloroform or ethyl chlorid. She should be 
placed across a bed or table and the thighs flexed upon the abdomen 
and the legs upon the thighs; the thighs should be rotated slightly 
outward. The obstetrician may then insert two fingers of one 
hand within the vagina, passing them directly back upon a line with 
the lower boixier of the symphysis pubis. If the head is engaged, 




Fig. 43. — Head in pelvic cavity (Bumm). 



his fingers will come against the head, which may or may not be 
still within the cervix. The upper portion of the vertex will be 
felt in occipital presentation. If the head is engaged, some portion 
of the sagittal suture will be recognized, the smaller fontanel usu- 
ally found, and if flexion is not complete, the larger fontanel may 
often be reached. To determine whether the head is engaged only 
in the upper pelvis, or whether it has entered the pelvic cavity with 
iiny portion of its circumference, the fingers should seek the spines 



120 OPERATIVE OBSTETRICS 

of the ischia. When the head has descended to a Une drawn between 
these spines, it has entered well into the pelvic cavity. Its suc- 
cessful passage through the pelvic cavity is, in the majority of cases, 
possible. If the head has not reached this point, the obstetrician 
must then determine wiiether or not he is dealing with a true engage- 




Fig. 44. — Anterior parietal presentation (Kerr). 

ment and descent of the head, or whether, in occipital presentation, 
labor has resulted in a presentation of a parietal bone. When this 
occurs, the head rotates upon its anteroposterior diameter, and a 
parietal bone passing downw^ard and forward occupies the greater 
portion of the space at the pelvic brim. If expulsive action is 



THE KXTHACTION OF THK CIIIIJ) THHOICH THE VA(;iXA 121 

vigorous aiul tluMV bo (lispri)})ortioii, the hvnd may become fixed 
in this position and impaction result. This condition is sometimes 
mistaken for engagement, and the application of the f()rce})s is 
made with disastrous c()ns{M[uences. Successful engagement in ver- 
tex presentation nHjuin^s dc^sccMit of the vertex with the smaller 




Fig. 4.3. — Posterior parietal presentation CKerr). 

fontanel, and the engagement of the head with the biparietal 
diameter in one of the oblique diameters of the pelvic brim. 

Brow presentation may also be mistaken for avorable engage- 
ment fFig. 48) the descent o the forehead being mistaken for one 
of the parietal bones, or for the vertex in face presentation (Fig. 49). 
The distance of the chin from the pelvic floor and the degree to 



122 



OPERATIVE OBSTETRICS 



which the face can be palpated will determine the degree of engage- 
ment present. In occipitoposterior cases engagement is deter- 




Fig. 46. — The engaged Iiead and amniotic liquid in normal pelvis (Bumm). 

mined by the distance of the posterior fontanel from the pelvic 
floor and the position of the sagittal suture. In breech cases engage- 




Fig. 47.- — The unengaged head and amniotic liquid in contracted pelvis (Bumm). 

ment is not complete until the obstetrician can reach with his fingers 
one of the child's groins. 



THE EXTHACTIOX OF THE (^IIIM) THKOLGH THE VAGINA 123 




Fig. 48. — Labor in brow presentation (Bumm). 




Fig. 49.— Face presentation— posterior rotation of the chin (Bumm). 

The importance of the recognition of engagement with begin- 
ning or partial descent can scarcely be overestimated in cases 
requiring artificial vaginal deliv(^ry. Error in this must result in 



124 



OPERATIVE OBSTETRICS 



the death of the child, and in the serious laceration, and even death, 
of the mother. 

While engagement and descent may not be present at the time 
of examination, they may still occur where disproportion is absent if 
the patient receives proper treatment, and vaginal dehvery may still 
become possible. In prolonged labor, if the patient's bladder be fre- 
quently emptied, if the rectum be empty, if she be turned upon the 




Fig. 50. — Miiller's method of endeavoring to fit the head into the pelvis in contracted 

pelvis (Bumm). 

side toward which the child's back is directed, if she be given liquid 
food sufficiently often and tonic doses of strychnin and brandy, 
engagement and descent may occur and vaginal delivery become 
possible. Where the patient is highly nervous and suffering, a few 
hours sleep under a full dose of morphin will often be followed by 
renewed uterine contractions, and engagement and descent. When 
pelvimetry shows that the pelvis is so small that engagement and 



THK KXTltACTIOX OF THE CHILD THliOlCIH THK VACIXA 



III 



descent cannot be expected, it is, of course, useless to wait for these 
phenomena; but in cases of sHght disproportion, where the patient 
has not received ade(|uate care (huing the early i)art of labor, and 
if she is in fair condition, it may be possible to perform vaginal 
delivery after securing engagement and descent by the methods 
described. 

In diagnosticating failure of engagement and descent through 
simple inertia, the operator must not neglect the possibilit}' of 




Fig. 51. — Flat pelvis. Ineffectual attempts at forceps deliverj- 

(Author's case). 



Porro operation 



rupture of the uterus. When this accident occurs, labor ceases 
suddenly with sharp pain, the uterus becomes very painful and 
tender upon pressure, fetal heart sounds cease, the patient is shocked, 
the pulse steadily rising. In simple inertia fetal heart sounds 
remain good, the patient is not shocked, labor does not cease sud- 
denly, the uterus is not tender, but sometimes partially relaxed; 
the patient may be fretful and irritable, but does not show signs 
of a dangerous complication. 



126 OPERATIVE OBSTETRICS 

The Condition of the Lower Birth -canal as Indicating the Pos- 
sibility of Vaginal Delivery. — One cannot determine the possibility 
and probable result of vaginal delivery without studying the size, 
development, and condition of the lower birth-canal. The head 
may engage and descend, but such difficulty may occur in its extrac- 
tion from abnormality in the lower birth-canal that fetal death 
and injury to the mother may result. Wilhams,^ in 1200 pelves. 




Fig. 52. — Justominor pelvis. Porro operation, after attempts at delivery by for- 
ceps (Author's case). 

found 10.17 per cent, funnel pelves contracted at the outlet. In 
these cases the transverse diameter at the outlet was reduced to 8 
cm., and the distance between the lower margin of the symphysis 
and the tip of the sacrum was less than 9 cm. Many of these cases 
were accompanied by sacrolumbar assimilation or the joining of 
the last lumbar vertebra with the sacrum. This deformity is much 

^ Surgery, Gynecology, and Obstetrics, June, 1909. 



THE EXTRACTION' OF THE CHILD THROUGH THE VAGIXA 



12- 



more coniinon in negro than in white women. In many cases a 
double sacral i)romontorv was present. In atti^mpting to deter- 
mine the possibihty of spontaneous labor it has been observed that 
when the transverse diameter of the pelvic outlet measures 8 cm., 
spontaneous labor cannot be expected unless the distance from the 
inferior border of the pubes to the tip of the sacrum is greater than 
its average normal length, 7.5 cm. If this compensation is not 




Fig. 53. — Irregularly contracted pelvis. Successful delivers' by celiohysterotomy 

(Author's case). 



established, spontaneous birth is unlikely and delivery by forceps 
may be diflBcult and attended with dangerous birth pressure. 

Although the existence of deformity in the pelvic outlet has 
long been recognized, its practical importance has not received 
due con.sideration. The maternal morbidity in these cases is high 
from extensive lacerations, which may be so severe as to induce 



128 



OPERATIVE OBSTETRICS 



a fatal termination. The maternal mortality is variously esti- 
mated, but is at least considerable, Walther concluding that 13.6 
per cent, of the mothers die and 25.7 per cent, of the children. 
In WiUiams' 122 cases with outlet contraction, 103 were delivered 
at or near full term without a maternal death, and with the loss of 
7 children. In these cases the deformity was recognized early 
and appropriate treatment applied as soon as needed. Thus, pubiot- 




Fig. 54. — Rachitic pelvis. Celiohy«terotomy (Author's case). 

omy was done three times in the series, forceps apphed ten times, 
and craniotomy performed once. 

It is evident that in these cases we lack the clinical test afforded 
early in labor by the engagement and partial descent of the head 
into the pelvic brim. Should the head become impacted low in 
the pelvis, delivery by abdominal section might be difficult or im- 
possible without fatal injury to the fetal skull in removing it from 
the pelvic cavity. In view of the dangers occasioned by contraction 
at the pelvic outlet, its measurement should be a part, of pelvimetry 
applied to all patients. Should the transverse diameter of the 



THE EXTRACTION OF THE CHILD THROUGH THE VAGIXA 129 

outlet bo considerably less than 8.5 cm., without compensating 
increase in the antero})osterior diameter above 7.5 cm., elective 
Cesarean section should be chosen. If, however, the transverse 
diameter be S.o cm. and the anteroposterior diameter 7.5 cm. or 
above, the descent of the child into the pelvis may be encouraged, 
and when the head reaches the pelvic floor, rotates, and appears 
at the vulva, should delay occur, a cautious application of the for- 
ceps may be made. If delivery is not then effected, pubiotomy 
should be performed. If this is impossible, craniotomy is indicated 
in the interests of the mother. 

Deficient development in the vagina and pelvic floor, malforma- 
tion and cicatricial contraction, and previous laceration or injury 
may make vaginal delivery dangerous to mother and child. If 
the conditions are not extreme, and the other factors in labor are 
normally present, the presenting part may be allowed to come upon 
the pelvic floor, and incision made, if necessary, to permit its deliv- 
ery. If the contraction of the soft parts is extreme, electiAT Cesarean 
section will be safest for mother and child. 

Bibliography of Vaginal Delivery: Conditions Favorable For 

Abdominal and Intrapelvic Methods of Deliver}^, Discussion on : Ameri- 
can Gynecological Society, American Journal of Obstetrics, 
July, 1908. 

Andrews and Maxwell: Journal of Obstetrics and Gynecology of the 
British Empire, April, 1908. 

Bayer: Monatsschrift f, Geburtshiilfe und Gj'nakologie, Band 24, 
Heft 1, 1906. 

Bunim and Blumreich: Atlas, Frozen Section, Wiesbaden, Bergmann, 
1907. 

Fruhinisholz : Zentralblatt f. Gynakologie, Xo. 31, p. 974, 1907. 

Fry: American Journal of the Medical Sciences, May, 1908. 

Gaussel-Ziegelmann : L'Obstetrique, March, 1907. 

Hermann: British Medical Journal, June 16 and 30, 1906. 

Hofmeier: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 59, 
Heft 2, 1907. 

Holden: Surgery, Gynecology, and Obstetrics, May, 1907. 

Holzapfel: Monatsschrift f. Geburtshiilfe und G^Tiakologie, Band 26, 
p. 633, 1907. 

9 



130 C?Z?.Ar3"E OBSTETF.ICS 

Jones: Journal of Obstetrics and GynecologT of the British Empire^ 

Xovember, 1906. 
Kocks: ZentralblatT f. Gynakologie. Xo. 52. 1907. 
Kriwski: Zentralblatt f. Gynakologie^ Xo. 47, p. 1491, 1907. 
Kronig: Monat^chrift f. Geburtshulfe imd Gynakologie, Band 23, 

Heft 3, 1906. 
Liv : : r. Discussion on: American Journal of Obstetrics, September. 190S. 
Leo: Zeitsehrift f. Geburtshiilfe raid Gynakologie, Band 58, Heft 1, 

1906- 
Martin: Archiv f. Gynakolo^e, Band 76, Heft 1, 1905. 
Mueller: Arehiv i. Gynakologie, Band 82, p. 410, 1907. 
Xorris: American Journal of Obstetrics. July. 1908. 
Owen: British Medical JoumnJ, March 10, 1906. 
Pankow: Zentralblatt f. Gynakolo^. Xo. 29. 1909. 
Reynolds: Transactions of the American Gynec-ological Society, 1907: 

American Journal of Obstetrics. August, 190S. 
Sehultze: Monat^chrift f. Geburtshulfe und Gynakologie, Band 25^ 

p. 571. 1907- 
Schutz : Monatsschrift f . Gebiui:shiilfe imd Gynakologie. Band 25. Heft 

5. ltX)7. 
Sellheim: Zentraibku f. Gynakologie, p. 17. 1907. 
Sirzenfrey: Zeitschrir: f. 'xebTirtsliTTiIfe und Gynakologie. Bi-ni oQ, 

Heft 3, 19a5. 
Stumpf: Arehiv f. Gynakl r-r I::: 1 S2, p. 215, 1107. 
Tri.>let: Zeitsehrift f. »> :iit^: _!:- \-d Gynakol-de. Ban.:! 54. Hefr 3. 

1'X».5. 
von Heru: Zentr^J 1:lt~ i '!-7ii:lkoL>gie. Xo. 4S. p. 1514. 1907. 
Winrer: DeLi-^eLe -r^. -V Ir^^.. Xo. lo. t>. 534. 1907. 

MANUAL EXTRACTION OF THE FETUS THROUGH THE VAGINA 
Mamial Extraction of the Head. — One of the earliest attempts 
at obstetric opemti»:>ns was the enort to extract the head with the 
hands from the vagLoa. It is probable that the shape of the hand, 
with its partially flexed fingers, suggesteii the shape of a forceps 
blade. Whei the head Ls upon the jiehric floor and delay occurs, 
it may be necessary for the operator to secure its expulsion by 
making traction upon the head with the hand: often the pelvic floor 
and perineum can be brought backward over the mouth and chin, 
and thus, by movement of extension, one extremity of the occipito- 
mental diameter of the head can be dehvered. The occipital end 



MANUAL EXTKACTION OF THE FETUS THROUGH THE VAGINA 131 

of this (liametrr is usually born witlunit difficulty. If it is neces- 
sary to make traction upon the head with the hands, the fingers 




Fig. 55. — The prevention of perineal laceration. The aceoucher is controlhng the 
passage of the head through the vulvar orifice (Kerr). 



of one hand may be placed over the occiput, the fingers of the other 
beneath the chin^ and gentle traction may be made, while the head 




Fig. 56. — The prevention of perineal laceration. The aceoucher, while maintain- 
ing the head in a condition of flexion, is now allowing it to escape from the vulvar 
orifice during the intervals between the pains (Kerr). 



is in midposition, neither flexed nor extended. In delivering the 
head manually care must be taken not to turn the head through 



132 



OPERATIVE OBSTETRICS 



too great an extent. Beyond ninety degrees, or the quadrant of a 
circle, the turning of the head is dangerous to the fetus. 

In difficult deUveries with face presentation, where the head is 
low down and the circumstances are unfavorable for the use of 
the forceps, the obstetrician may succeed by getting his finger in 
the child's mouth, and rotating and delivering the chin, and thus 
securing subsequent expulsion of the head. To avoid severe injury 
to the child the fingers in the mouth should not exert strong or 




Fig. 57. — Spontaneous birth, face presentation (Bumm). 



sudden pressure, as it is possible to separate the lower jaw at its 
symphysis by so doing. 

Manual Extraction of the Shoulders. — After the birth of the 
head, delay of varying length in the expulsion of the shoulders is 
not uncommon. This is rarely dangerous, but circumstances may 
arise which make it desirable to deUver the mother as soon as pos- 
sible. 

To rotate the shoulders quickly the patient should be placed 



MANUAL EXTRACTION OF THE FETUS THROUGH THE VAGINA 133 

upon the edge of a bed or table, so that the oj^erator can depress 
his elbow and introduce his fingers as high as possible. If she is 
restless and struggles, she should be at least partially anesthetized. 
The efifort should first be made to reach the lower shoulder bj' pass- 
ing the fingers of the hand corresponding to that side of the mothers 
body to which the back is directed along the j^elvic floor and up 




Fig. .58. — Delivering the posterior shoulder (Bumm). 

into the pehis as high as possible, at the side of the promonton' 
of the sacrum. If the fingers be then bent forward toward the 
pubes. one or two can usually be introduced into the axilla, when 
traction downward will deliver the posterior shoulder. A similar 
maneuver upon the opposite side will usually be successful. 

Where the shoulders cannot be rotated from below, very gentle 
traction may be made upon the head, grasping the occiput and chin 



134 OPERATIVE OBSTETRICS 

and avoiding flexing or extending the head. Such traction should 
be downward and backward in the axis of the pelvic brim. This 
may be reinforced to advantage by causing the uterus to contract 
through massage, and by pressing downward and backward behind 
the symphysis pubis, the urinary bladder being first emptied by 
catheter. 



rig. 59. — Delivering the posterior shoulder in vertex presentation, the mother 
lying upon her back (Nagel) . 

In extreme cases, where fetal death has occurred when the 
shoulders are impacted, cleidotom}^ may be necessary. This con- 
sists in severing the clavicle, one or both, with blunt-pointed scis- 
sors. The effect of this is to cause the shoulder to collapse and 
reduce the bisacromial diameter, very greatly lessening the size of 
the fetal trunk and permitting its descent and extraction. In the 
dead fetus the insertion of Brown's decapitation hook into the 
axilla will greatly facilitate the delivery of the child. 



MANUAL EXTRACTION OF THE FETUS THROUGH THE VAGINA 135 

The Delivery of the Presenting Arm. — When an arm prolapses 
the first impulse of a midwife^ or friend of the patient is to pull 
upon the arm in the effort to extract the cliikl. This will cause 




Fig. 60. — Impaction of anterior shoulder behind the pubes (Bumm). 



fracture of the humerus or clavicle, and if the effort excites uterine 
contractions the shoulder will be wedged firmly into the pelvic 
brim. If the shoulder has descended sufficiently far and allowed 
the arm to prolapse, version or embryotomy is necessary. Only in 



136 



OPERATIVE OBSTETRICS 



the case of an abnormally small fetus, or of a dead and macerated 
fetus, could traction upon the arm secure delivery. 




Fig. 61. — Spontaneous birth: the head having been expelled, the upper shoulder is 
" ' - brought beneath the pubis' (Xagei).-" "— "- • - 



The Manukl' Delivery of the Child Prese^titing' by the Lower Ex'- 
tr emities and Breech ' (Breech Extraction) . — In' itreet^h" extraction, 

where delay occurs in delivery, the obstetrician will naturally attempt 
to bring clown 'th'e -hips'- b}- traction with the fingers. Although 



MANUAL EXTRACTION OF THE FETUS THIIOUGH THIO VAGINA 137 

the broecli may bo a})pareiitly inaccessible, he must not despair until 
a thorough effort has been made, under ether, to introduce the 
fingers into the child's groin. By (Etherization uterine contrac- 
tions are often excited, and this, with the relaxation of the pelvic 
floor which accompanies etherization, will often bring the hips down 
so that the groins will be accessible. When the patient is anesthet- 
ized, with her hips upon the edge of a high bed or table, the opera- 




Fig. 62. — Child in Vjreech presentation with the lower extremities extended. 

tor should pass two fingers along the posterior wall of the vagina 
upward into the pelvis, along the side of the promontory of the 
sacrum, and endeavor to hook the fingers into the groin of the fetus. 
Operators sometimes prefer to pass the fingers up the side of the 
pelvis and introduce them above the femur, carrying them toward 
the trunk of the child's body into the groin. Care must be taken 
that the fingers get completely to the groin, and that pressure is 
not made upon the middle of the femur. Should such occur, frac- 



138 



OPERATIVE OBSTETRICS 



ture of the femur may be the result. Traction by the fingers in the 
groin may be supplemented by uterine contractions excited through 
massage and by suprapubic pressure downward and backward, 
when the posterior hip is thus dehvered; the anterior will usually 
follow without much difficulty by the same procedure. 




Fig. 63. — Breech presentation: grasping and bringing down the breech of the 
child, the lower limbs extended and the back posterior; first position (Farabeiif 
and Varnier). 

Should the fingers fail to reach the child's groin after a patient 
and thorough effort, and delivery be imperative, the breech may 
be brought down by the blunt hook. This should be passed along 
the posterior portion of the pelvic cavity, along the abdomen of 
the child, and the point shpped over the brim of the pelvis into the 
child^s groin. The delay in these cases usually makes the child's 
fife a doubtful one, and in the interests of the mother deUvery should 



MANUAL EXTRACTION OF THE FETUS THROUGH THE VAGINA 139 

be eftVctod, vwn with t^oiiic injury to the child. In dead and macer- 
ated chikh-en the ])oint of the blunt hook may be carried into the 
abdominal wall, or ovc^r the brim of the pelvis into the muscles about 
the ilium. If the child is in fair condition, care must be taken to 




Fig. 64. — Breech presentation: first position; extraction of the breech by traction 

upon the groins (Nagel). 

introduce the hook into the groin only, or upon the crest of the 
ilium, making as gentle traction as possible. Traction shoukl then 
be made downward and backward until the hips descend to the 
pelvic floor, when the posterior hip should be delivered first by trac- 
tion upward and forward. 



140 



OPERATIVE OTBSTETRICS 




Fig. 65. — Bringing down the body of the child. Breech presentation: second posi- 
tion (Farabeuf and Varnier). 




Fig. 66. — Bringing down the body of the child by traction upon the groin; breech 
presentation (Farabeuf and Varnier). 



MANUAL EXTRACTION OF THE FETUS THROUGH THE VAGINA 141 




Fig. 67. — Traction in both groins (Farabeuf and Varnier). 




Fig. 68. — Breech presentation. Delivery of the child by traction in the groins 

(Farabeuf and Varnier). 



The application of the forceps to the undescended breech is 
described under the head of Forceps Delivery, p. 163. 

In cases where one leg prolapses and delay occurs in the descent 



142 



OPERATIVE OBSTETRICS 



of the breech, an effort should be make to hook the fingers into the 
groin on the side of the retained leg, and this, combined with trac- 
tion upon the prolapsed Umb, should bring down the breech. Should 
the groin be inaccessible, the body can be brought clown by gentle 
traction upon the prolapsed thigh, supplemented b}'' uterine contrac- 




Fig. 69. — Breech presentation, with the lower limbs, one flexed and one ex- 
tended. Delivering the posterior hip by traction upon the crest of the fetal ilium 
(Nagel). 

tions and suprapubic pressure. As soon as the groin is accessible, 
the breech and limbs should be delivered. In severe cases of fetal 
impaction,, where the child is dead, the blunt hook may be used, 
together with traction upon the prolapsed extremity. 

The Delivery of the Trunk and Upper Extremities. — During the 



MANUAL EXTRACTION OF THE FETUS THllOUGII THE VAGINA 141^ 




Fig. 70. — Delivery in breech presentation: bringing down the child by traction from 
the thighs (Farabeuf and Varnier). 



^y?C^.rr^ 




Fig. 71. — Breech presentation: bringing down the arm (Farabeuf and Varnier). 



delivery of the lower extremities and breech the operator should 
take the opportunity to secure anterior rotation of the child's back. 



144 



OPERATIVE OBSTETRICS 



Under anesthesia this can be accomplished and is of great value in 
securing a favorable delivery of the after-coming head. When the 
operator can grasp the lower hmbs, the patient being anesthetized, 
he can rotate the back of the child anteriorly by gradual manipu- 
lation. The back need not point directly to the pubes, but obliquely 
forward and slightly outward. 




Fig. 72. — Breech extraction. Rotating the breech to bring the back anteriorly 
by traction upon the thigh and leg. 

In delivering the trunk and upper extremities, as well as the 
lower extremities, the parts of the child external to the mother 
should be wrapped in a warm sterile towel. This has a two-fold 
advantage — avoiding intra-uterine respiratory effort and giving the 
operator a much better grasp upon the fetus. 

In order to successfully deUver the body, upper extremities, and 
head the patient must be on her back completely upon the edge of a 
high bed or suitable table. The thighs should, if possible, be held 



MANUAL EXTRACTION OF THE FETUS THROUGH THE VAC;iNA 145 

by a.^sistants, as it may bc^ iiccossary to change the position of the 
thighs when th(^ head reaches th(^ pelvic floor. The patient should 
be under c^tlun", adniinistcMXHl by a competent obstetrician, as aid will 
be neecUnl in manipulating tlu^ utc^'us and in making downward and 
backward pressure during the delivery of the head. The operator 
should have at hand the obstetric forceps with axis traction, gauze 




Fig. 73. — Breech extraction. Rotating the back anteriorly by traction upon the 

thighs. 

for intra-uterine packing, catheters for draining the bladder, materials 
for closing lacerations, and appropriate stimulants. The fetal body 
should be brought as far down as possible without traction by uter- 
ine contractions excited by massage and by pressure. The fetal body 
should be allowed to hang, moving freely, so that its weight may 
assist in descent. When the child is born up to the shoulders, if 
the back be directed toward the mother's left thigh, the operator 

10 



146 



OPERATIVE OBSTETRICS 



should grasp the lower extremities of the child, wrapped in a warm 
towel, in his left hand, and the fingers of the right hand should be 
placed upon the shoulders of the child. The child's body should 
be drawn strongly but gently downward and backward, rotating the 
body obliquely in the pelvic brim. It should then be raised strongly 
upward and obliquely outward, when the posterior shoulder will 




Fig. 74. — Bringing down the arm extended over the face (Farabeuf and Varnier). 

frequently descend upon the pelvic floor. If it does not do so, the 
obstetrician should pass his right hand over the child's back and 
right shoulder, bringing the fingers down upon the anterior surface 
of the right humerus to the elbow. Gentle pressure should then 
be made in the bend of the elbow, and the elbow carried gently 
across the anterior surface of the child's body. With this motion the 
child's arm may be brought down and delivered at the vulva. Care 



MANUAL EXTRACTION OF THK FETUS THROUGH THE VAGINA 147 

should be taken not to make pressure u})on the shaft of the humerus, 
as fracture will almost ccitainly result. 

When the lower shoulder has been delivered, the lower extrem- 
ities of the child, wrapped in a warm sterile towel, should be firmly 




Fig. 7.5. — Breech presenration: second position: the arms extended above the 
head; bringing down the arms v^^agel). 

grasped and the bod}- carried oblicjuely upv.-ard and outward to the 
opposite .side. If the fingers be then passed over the back and 
along the humerus to the elbow, anrl gentle pressure made in the 



148 



OPERATIVE OBSTETRICS 



bend of the elbow, the arm can be swept across the child's chest 
and delivered. These manipulations, to be successful, require 
strength and patience, and familiarity with the mechanism of labor 
and the contour of the pelvic cavit3\ Anesthesia is absolute^ 
requisite for such successful manipulation. 




Fig. 76. — Breech presentation: second position; the posterior arm dehvered; 
rotating the child's body in the direction of the arrow to bring the other arm into 
the hollow of the sacrum for delivery (Xagel). 



In difficult cases with fetal impaction the effort to reach the 
extended arm with the fingers may fail. In such cases the integ- 
rity of the arm and shoulder must be sacrificed in the interests of 
the mother. The arm may be brought do\Mi with a blunt hook or, 
if the fetus be dead, the decapitation hook fixed above the clavicle 
and traction made upon the clavicle, fracturing it, or the hook 



MANUAL EXTHACTIOX OF THE FETUS THH()U(;H THE VAGINA 149 

may bccoino burial in the tij^suos, and shoulder and arm may thus 
be brought down. In transverse position with impacted shouldcu", 
with wedge formation of the fetus, it is often necessary to ampu- 
tate the upper extremity and })erform cleidotomy to decompose 
the wedge. The fetal shoulders and head arc then shoved upward 
and the lower limbs brought down and delivery terminated. 

The Delivery of the After -coming Head. — The success of this 
maneuver depends upon the absence of great disproportion between 




Fig. 77. — Breech extraction. Raising tlie body of the fetus wrapped in a towel, 
while the operator, with the other hand, makes pressure behind the pubis. 

mother and child, the posture of the patient, intelligent assistance 
and anesthesia, and prompt manipulation on the part of the opera- 
tor without undue haste. The patient should be upon her back at 
the edge of a high bed or table, her thighs flexed by assistants and 
rotated outward. As the body of the child emerges it should be 
wrapped in a warm sterile towel and the thighs grasped by the 
hand of the operator. As the head enters the pelvic brim, the 



150 



OPERATIVE OBSTETRICS 



operator should lay his free hand across the body of the mother, 
just above the symphysis pubis. The child's body should then 
be raised and brought upward and backward over the abdomen 
of the mother; simultaneously pressure should be made downward 
and backward behind the pubes. In the majority of cases this 
manipulation will cause the prompt birth of the head. 




Fig. 78. — Breech extraction: making traction upon the breech. 

To be successful, the patient must not resist, struggle, or draw 
backward. It is rarely possible to control a patient without anes- 
thesia, and, hence, ether should be given in these cases. Anesthesia 
should not be very deep, but sufficiently so to make the patient 
perfectly manageable. Although the operator is tempted to act as 
rapidly as possible, he should remember that observation has shown 
that from three to five minutes may be spent in the extraction of 



MANUAL EXTKACTIOX OF TllK FETIS THllOU(;H THF VAGINA 151 

the after-coming head without injury to mother or child. Th(^ rai)id 
(.lelivery of the after-coming head may cause severe lacerations, and 
also imperil the child's life. The operator then should move promptly; 
but without undue haste. 

Should this manipulation fail, the child should be placed astride 
the arm of the operator, and the long finger of the operator's hand, 
thumb upward, should be inserted in the child's mouth; some prefer 




Fig. 79. — Breech extraction. The child astride the left arm of the operator, 
the right hand being placed upon the shoulders, while an assistant makes pressure 
above the pubes. 



to insert two fingers. The remaining fingers of this hand should be 
bent over the child's shoulders to give a firmer grasp upon the body. 
AVith these fingers the child's head is brought dow^nw^ard and back- 
ward, flexion being maintained l\v the fingers in the mouth. The 
other hand of the operator should be placed behind the pubes, pres- 
sure being made downward and backward in the axis of the pelvis. 
B)^ raising the child's body with the arm w-hich supports it, and by 



152 



OPERATIVE OBSTETRICS 



the downward and backward pressure of the external hand, the 
child's head is brought over the pelvic floor. To be successful this 




Fig. 80. — The delivery of the after-coming head with the occiput posterior, Prague 

method (Kerr). 



manipulation requires absolute control of the patient, moderate 
surgical anesthesia, the patient in favorable position, the urinary 
bladder being completely emptied by catheter, and familiarity with 
the anatomy of the pelvic cavity and with manipulation of the fetal 
head. After the head passes through the pelvic brim and comes- 



MANUAL EXTHACTIOX OF THE FETUS THROUGH THF VAGINA 153 

upon the pc^lvic floor, the thighs of the i)atient may be allowed to 
descend, although they should he earried asunder. This maneuver 
facilitates the extraction of the head. 




Fig. 81. — The operator rlelivering the after-coming head by traction in the mouth 
and suprapubic pressure combined (Nagel) . 

. Should the delivery of the head fail by manual efforts, the 
use of the forceps is indicated. The instrument should ]:>e placed 
upon the sides of the child's head, a firm but gentle gras}) ob- 



154 



OPERATIVE OBSTETRICS 




^r^^r 



Fig. 82. — Breech presentation: delivering the after-coming head. The right 
hand of the operator is placed over the child's shoulders; the long finger of the 
left hand, palm uppermost, is placed in the child's mouth. The child is astride 
the operator's left arm, and pressure is made by an assistant upon the retained 
head through the abdominal and uterine wall (Xagel). 



MANUAL EXTUACTION OF THE FETUS THROUGH THE VAGINA 155 

taincd, and axis-tractioii be practised downward and backward 
until tlie pelvic floor has been reached. A forceps of considerable 




Fig. 83. — The final delivery of the after-coming head in breech presentation (Nagel). 

length is necessary for this manipulation, and Simpson's, with axis- 
traction, or Tarnier's will be found useful. When the head reaches 



156 



OPERATIVE OBSTETRICS 



the pelvic floor it may be delivered in the usual manner. During 
the application of the forceps the body of the child must be 
raised out of the way of the operator by an assistant, and this 
manipulation will assure the descent of the head and facilitate the 
apphcation of the forceps. 




Fig 84. — The delivery of the after-coming head by forceps (Kerr). 

Should the head become extended, the back of the child rotat- 
ing anteriorly, under complete anesthesia, the operator should en- 
deavor to introduce the fingers into the mouth and draw down the 
chin. If this can be done, he may proceed to deliver the child in 
the usual manner, with the fingers in the mouth. Should the chin 



MANUAL EXTKACTION OF THE FETUS THROUGH THE VACilXA 157 




Fig. 85.— The after-coming head in flexion (Nagel). 




Fig. 86.— The after-coming head in partial extension (Nagel). 

become impacted, the life of the child will be lost, and craniotomy 
upon the after-coming head will be the operation of choice. 



158 



OPERATIVE OBSTETRICS 



In cases where the obstetrician has charge of the patient from 
the beginning of labor he can secure anterior rotation of the body 
by manipulating the lower extremities and the breech. In neglected 
cases he may not be called to the patient until the body of the child 
has been born, the shoulders and head remaining within the uterus. 
He may then find the back posterior, the thorax anterior, and the chin 
above the pelvic brim with strong extension. The child is, in the 
great majority of cases, dead when the physician sees the patient. 




Fig. 87. — The bimanual delivery of the after-coming head. Flexion maintained 
by introducing the fingers into the child's mouth (Farabeuf and Varnier). 



In these cases nothing can be done without complete anesthesia. 
Unless the facilities for operation are good, such a case must be 
transferred to a maternity hospital. After proper preparation 
under complete anesthesia, the patient may be turned upon her 
side, the upper thigh raised, and the body of the child drawn back- 
ward over the anus of the mother. The operator should then in- 
troduce as much of the hand as possible, endeavoring to reach the 
chin. This should be brought down, if possible, in the obUque 



MANUAL EXTRACTION OF THE FETUS THROUGH THE VAGINA 159 

diameter of the })elvic cavit}', and the head extracted. Should 
manual extraction fail after the cliin has descended, the forceps 
may be tried. Gentle traction only should be made, and if this 
fails, craniotomy upon the after-coming head is required. 

Complications of Breech Extraction. — Extraction by the breech 
is especially dangerous for the infant. The exposure of its body to 
a lower temperature favors intra-uterine respiration, and inspiration 



^:.4. 




Fig. 88. — Dislodgment of the chin in the after-coming head (Bumm). 

pneumonia may result. Pressure upon the trachea may have a like 
effect. Pressure upon the cranium during rapid forcible extraction 
through the bony pelvis may fracture its bones and produce cerebral 
hemorrhage. The fetal mortality of breech extraction is variously 
estimated at from 10 to 30 per cent. To succeed in this maneuver 
the operator must constantly keep in mind the anatomy of the pelvic 
cavity and of the fetal head. In bringing the head through the 



160 OPEKATIVE OBSTETRICS 

pelvis the bitemporal diameter will fit most safety in the antero- 
posterior diameter of the pelvic brim. The occiput can best be 
accommodated at one side of the promontory of the sacrum^ the 
face and chin at the anterior extremity of the obhcjue diameter. 
AYhile passing the promontory the head may be practically transverse 
in the pelvis, but as soon as possible it should assume an oblique 
position and thus descend to the pelvic floor. If the head passes in 
the axis of the pelvis undue oblicjuit}' will not develop, otherwise the 
presentation of a parietal bone may occur with impaction, fol- 
lowed by fetal death. Should extension become extreme, the chin 
may become impacted, with a like result. Fracture of the skull 
usually occurs while the head is passing the brim of the pelvis. 
Dangerous pressure, causing respirator}^ complications, takes place 
while the child's head is upon the pelvic floor and outlet of the 
vagina In cases where disproportion is present, Walcher's posi- 
tion, at the moment when the head is passing the brim of the pel- 
vis, may be of great value. While strong traction may be neces- 
sary, it should be exercised as gradually as possible and deliberate^. 
The same caution is necessary in the delivery of the child over the 
pelvic floor. Rapid breech extraction causes severe lacerations in 
primiparous patients, which ma}' be follovred by alarming hemor- 
rhage. In difficult cases episiotomy may be demanded. Prolapse 
of the cord is a further complication of breech extraction, and in 
manipulating the child the cord should be kept at the side of the 
promontor}^, if possible, where it will escape dangerous pressure. 
Should the cord become pinched between the child and the pehds, 
the body of the child should be rotated slightly in the effort to relax 
the pressure. Should this fail, deliver}^ must be expedited as greatly 
as is safe. Fractures of the humerus, clavicle, and skull, subluxa- 
tions of the shoulder, elbow, and cervical vertebrse in the fetus may 
occur during breech extraction. Before operating the obstetrician 
should inform the husband of the patient, or her nearest responsible 
relatives present, that the condition is an abnormal one and that 
danger to the fetus is inevitable. Appliances for resuscitating the 



MANUAL EXTRACTION' OF THE FETUS THROUCH THE VAGIXA IGl 

child, for i)ro(liR*iiig artiHeial ivspiration, for the appUcalion of 
heat, and skiU'iil care, should Ix^ at hand. 

Breech Extraction With Premature Fetus. — In hemorrhage, 
toxemia, and other coneUtions threatening tlie mother's hfe, preg- 
nancy may be terminatal in her interests. The fetus is often dead 
in these cases, and its small size and the partial dilation of the 
uterus may make its extraction difficult. The head may be severed 
from the body and retained within the womb. In operating upon 
these cases sufficient dilation, if possible, must be seciu'ed. As 
the child is premature or dead, haste in its interest is not necessary, 
and the operator should use the body of the fetus as a dilator. If 
the head be separated and retained, it may be extracted with strong 
serrated forceps, with placental forceps, or the uterus may be 
packed with gauze and no further eftort made at extraction. AVithin 
forty-eight hoiu-s the uterus will expel the greater part of the gauze 
and the retained head. 

Breech extraction should not be undertaken unless the operator 
is prepared to immediately close lacerations and control hemorrhage. 
AVhile the operation is often thrust upon the general practitioner in 
private houses, he is placed at great disadvantage, for its proper 
performance recjuires a good table or high bed, a competent anes- 
thetizer, and skilled assistants. Breech cases recjuire the services of 
several physicians, and should, if possible, be conducted in a hospital. 

Breech deUvery may be indicated after vaginal Cesarean sec- 
tion, after pubiotomy, and after suprasymphyseal extraperitoneal 
section. In these cases, while the operator naturally desires to 
save the child, he must remember that the mother is in especial 
clanger. After vaginal Cesarean section and suprasymphyseal 
section the head must be brought through the lower uterine segment. 
In breech extraction this tissue could readily be torn and serious 
consequences follow. After pubiotomy, when the child is extracted 
by the breech, the head may bring the vaginal tissties against the 
severed ends of the pubic bones, and severe lacerations opening into 
the pelvic and peritoneal cavities have resulted. Breech extraction 
11 



162 OPERATIVE OBSTETRICS 

for these operations must be conducted with especial care to avoid 
lacerations. 

In placenta prsevia treated by combined version, with the bring- 
ing down of the breech, if the mother's interests are to be considered, 
the operator must avoid rapid extraction. The child's body is to 
be used simply as a plug, and remain upon the pelvic floor until the 
uterus contracts and expels it or forces it doT\Tiward (Fig. 129, p. 216). 
As soon as the hips appear at the vulva, or as soon as both lower 
limbs have been brought down, so that the body is under control^ 
efforts at extraction should cease. When the uterus acts, the child 
should be delivered very slowly and the uterus followed down 
and massaged by an assistant. The birth of the child should be fol- 
lowed by measures to prevent relaxation and hemorrhage. Until 
the body of the fetus is partly delivered the uterine muscle should 
be kept in tonic condition b}^ strychnin and ergot. 

Bibliography of Breech Extraction 

Cohen: Zentralblatt f. Gynakologie, p. 196, 1907. 

Cukor: Zentralblatt f. Gynakologie, Xo. 19, 1908. 

De Normandie: Surgery, Gynecology, and Obstetrics, April, 1908. 

Eisenstein: Zentralblatt f. Gynakologie, No. 3, 1909. 

Fiirst: Zentralblatt f. Gynakologie, Xo. 32, p. 981, 1907. 

Garipny: Zentralblatt f. G^^nakologie, Xo. 30, p. 942, 1907. 

Groeschel: Zentralblatt f. Gynakologie, Xo. 46, p. 1456, 1907. 

Hammerschlag : Monatsschrift f. Geburtshlilfe und Gynakologie, Band 

25, p. 245, 1907. 
Hofbauer: Zentralblatt f. Gynakologie, p. 354, 1907. 
McKerron: Journal of Obstetrics and Gynecology of the British Empire^ 

Xo. 4, 1907. 
Miiller: Zentralblatt f. Gynakologie, Xo. 32, p. 979, 1907. 
Nijhoff : Zentralblatt f. Gynakologie, Xo. 25, 1907. 
Reber: American Journal of Obstetrics, vol. 55, p. 89, 1907. 
Riihl: Zentralblatt f. Gynakologie, Xo. 31, p. 958, 1907. 
Schulz: Inaug.-Diss., Breslau, 1905. 
Veit: Zentralblatt f. Gynakologie, Xo. 23, 1907. 
Ziegelmann: L'Obstetrique, March, 1907. 



delivp:ky by forceps 163 

DELIVERY BY FORCEPS 

It seems more than probable that the shaj^e of the hand suggested 
to Palfyn and Chamberlain the shape of the cephalic portion of the 
forceps. As any one attempting to extract the presenting part with 
the two hands would hold the arms parallel during the attempt, 
so the first obstetric forceps was not crossed, but two blades were 
held parallel and bound together with a leather thong. The danger 
of presstu-e upon the cliild's head must have been less in this way 
than when the blades were crossed, l^ut the security in fastening 
was also less and the grasp upon the head not as secure. 

The Forceps as An Instniment. — So many have been the modi- 
fications of the forceps by different operators that the attempt to 
describe them all would fiu-nish an instrument-maker's catalogue of 
considerable size. We shall confine oiu' attention to the forceps 
most in use. 

Li America and England the Simpson forceps is that commonly 
employed: in France, the Tarnier: in Germany and Austria, the 
Xaegele. The Simpson is remarkable for its solid construction, the 
ease with which it locks, its ready application, and its great titility. 
Its blades, when closed, are ftuther asunder than those of the Tarnier 
or Xaegele forceps. They distend the mother's tissues more gTeatly 
and tend slightly to greater laceration. On the other hand, when 
closed the Simpson forceps exerts less presstu*e upon the head than 
do the other varieties. The length of the Simpson forceps, as ordi- 
narily made, is such that it can usually be appUed at the brim of the 
pehis successfully. 

The Tarnier forceps is remarkable for its length, close approxi- 
mation of its blades, its narrowness with the blades closed, and its 
axis-traction attachment. It is especially useful in the high appli- 
cation of the forceps, with the presenting part engaged in the pelvic 
brim. Its narrower blades make it a good instrument for use in 
primiparse. When accurately applied to the sides of the head and 
in skilful hands the Tarnier forceps gives excellent results. It may 
cause dangerous birth pressure if improperly appUed, is not so easily 



164 OPERATIVE OBSTETRICS 

applied or locked as the Simpson forceps, and is not applicable in so 
large a number of cases. 

The Naegele forceps has blades narrower than the Simpson, 
locks with a button and a notch, and is of average length. It has 
no axis-traction device. It should be applied to the side of the 
head and can exercise very strong pressure upon the fetal cranium. 

The Solid-bladed Forceps. — Many of the earlier forceps had solid 
blades, and such an instrument is occasionally used at present. Its 
blades are long and narrow, the pelvic curve of the average, and 
the advantage of the instrument lies in the fact that with it the 
fetal head may be rotated without the danger of including maternal 
tissue in the grasp of the forceps. Its utility is limited and it is not 
in extensive use. 

Good and Bad Forceps. — Good forceps are made of thoroughly 
tempered steel, sufficiently heavy to be strong, have proper curvature, 
are well plated, and smoothly finished. The various parts of the 
instrument fit properly and the instrument is of requisite length. 
Bad forceps are made of imperfect steel, are light in weight, badty 
finished, with inferior appliances. While one cannot test forceps 
before purchasing, so many instruments are sold that it is well to 
examine critically before buying. 

Essential Portions. — The cephafic portion of the forceps, fitting 
upon the head, should be of sufficient size, when applied over the 
parietal bones, to have the parietal protuberances lie in the middle 
of the fenestrse. The blade should extend to the posterior portion of 
the parietal bone, without projecting to any extent beyond. The 
fenestra should be sufficiently large to allow the ear of the average 
full-term child to pass through it or lie within it without dangerous 
pressure. 

The lock of the forceps should be readily adjusted and secure. 
For practical purposes the Simpson lock, if properly used, is least apt 
to cause injurious birth pressure, and is most easily adjusted; it can 
readily be loosened by slight motion of the blades, allowing, if desired, 
a slightly different application. The most complete lock is that of 



d?:livekv by FORC?:rs 165 

the Tariiier forcops, whoso coiiibinetl screw not only keei)s the blades 
together, but is reinforced by a transverse screw, whose force is 
exerted toward tlie proximal extremity of the blades. The button 
and notch lock is easy to adjust, but less efficient than the others. 

The handles of most forceps now made are of steel, nickel-plated; 
to reduce the weight of the instrument they are often hollow, and 
aluminum is. sometimes combined with steel for lightness. The 
handles should be large enough to afford a firm grasp by a large-sized 
male hand. They may be corrugated and at the distal extremity 
have a shoulder projection, which in Hodge's forceps was turned into 
a blunt hook for extraction. If rubber is used upon the hajidles, it 
must be so well made that the forceps can be boiled repeatedly with- 
out injury to the rubber. Such can be made by good workmen. 
The forceps is said to have a cephalic and pelvic curve. The 
cephalic is that in the portion of the bJades fitting over the head, 
and is intended to permit the firm and accurate grasp of the pre- 
senting part. The pelvic curve enables the operator to pass the 
instrument upward into the pelvic brim. The curves of good for- 
ceps differ very little, that of the Tarnier being adapted for high 
application. 

Axis -traction. — As the name indicates, axis-traction consists in 
pulling in the axis of the pelvis. Although this phrase is commonly 
used, it is more accurate to say that axis-traction consists in pulling 
in the axis of the birth-canal. This differs from the pelvic axis in 
that the axis of the birth-canal extends downward and backward 
to the pelvic floor, and then upward and forward. The axis of the 
pelvis is a curved line which does not pass to the pelvic floor. In 
using the forceps the axis of the birth-canal is followed, for it is 
often necessary to bring the presenting part strongly down upon the 
pelvic floor, whose aid is desired in securing rotation. Delivery is 
then effected by traction upward and forw^ard until the vertex passes 
beneath the pubes. 

Axis-traction may be effected by an experienced operator with 
forceps having no appHances for axis-traction. This is accomplished 



166 



OPERATIVE OBSTETRICS 



by placing one hand firmly across the forceps applied to the head at 
the lock, if possible, just in front of it. Pressure is then made down- 
ward and backward with this hand; when the pelvic floor is reached, 
the other hand grasps the distal extremity of the blades and pulls 
upward and forward. While this maneuver may answer in cases 
not difficult, in those requiring prolonged traction, with difficult de- 
scent of the fetuS;, this method is inefficient. 




Fig. 89. — Tarnier's forceps. 

Axis-traction may also be made in a simple and more or less 
efficient manner by passing a loop of stout cord about the forceps 
just in front of the lock. This cord is sufficiently long to reach 
nearly to the floor from the bed or table on which the patient lies. 
Placing one foot in this loop of cord the operator may make traction 
downward, while with the hands grasping the forceps handles he may 
direct traction and, when desired, pull upward and forward. Axis- 
traction may also be made by detachable hooks applied to the shanks 



DELIVERY n\ FORCEPS 



16; 



of the forceps between the lock and the handle or at the posterior 
extremity of each fenestra. This method has been extensively used 
and reeonnnended by Reynolds and others. 

]^ut these substitutes for axis-traction appliances are unsatisfac- 
tory and should be employed only in the lack of something better. 
Tarnier's axis-traction appliance leaves nothing to be desired from 
the standpoint of mechanism; it is, however, at times not easy of 
application. It applies its traction at the sides of the blades near 
the posterior extremity of the cephalic portion. Reynold's hooks 
and Murray's detachable handles may be applied to the posterior 
extremity of the fenestrated portion of the blades. This point of 




Fig. 90 — Simpson's forceps, tape attachment without traction bar. 

apphcation is practically that of the Tarnier. In other axis-traction 
forceps, axis-traction mechanism is apphed to the handles, near or 
just anterior to the lock. The point of application of the axis-trac- 
tion mechanism is important because it has to do with the securing 
of complete flexion of the head. Furthermore, if the force exerted 
upon the head can be applied opposite the parietal eminences at the 
middle of the head, more efficient traction will follow. 

Poulet's Tapes. — Poulet applied to a long narrow^-bladed forceps 
tapes passed through apertures in the cephalic portion of the blade 
at its middle. These tapes were then fastened on an axis-traction 
handle, by which force was exerted downward and backward. This 
handle was bent at its distal extremitv at riaht ans-les with its first 



168 



OPERATIVE OBSTETRICS 



portion^ which was parallel with the pelvic floor during application. 
The advantage of the Poulet tapes lay in the fact that the traction 
was applied opposite the center of the fetal head, which was accom- 
plished by no other instrument. The tapes occupied little room, were 
easily applied, could be easily sterilized, and destroyed after use. 
The disadvantage of the tapes lay in the fact that with strong trac- 
tion they sometimes broke, and if carelessly used they cut the mucous 
membrane of the birth-canal. The writer has utilized them in 
connection with Simpson's forceps in a veiy satisfactory manner. 
The Simpson forceps is made a little heavier than the ordinar}^ instru- 




Fig. 91. — Simpson's forceps, tape attachment and traction bar. 
ment, and apertures large enough to permit the apphcation of tapes 
are placed at the middle of the cephalic portion of the blades. The 
best quality of linen tape is selected, and passed through these aper- 
tures from without inward. If desired, they may then be passed 
through the traction bar, as shown in the accompanying illustra- 
tion. Practically it is seldom necessary to use the traction bar, for 
the operator can grasp the tapes in one hand, making traction 
downward and backward, and controlling the movements of the head 
with the handles of the forceps grasped in the other. A consider- 
able experience by myself and others has shown the practical value 



DELIVIOHY BY FORCEPS 



1G9 




Fig. 92. — Impaction of the breech. Delivery by means of forceps (Kerr). 



of this instrument. The breaking of the tapes is of very rare occur- 
rence and does no harm. The point of apphcation of the axis-trac- 
tion prockices excellent flexion of the head, and in posterior rotation 



170 



OPERATIVE OBSTETRICS 



of the occiput; where anterior turning completely fails and the occi- 
put must be delivered from behind, we have been able to deliver 
cases with this instrument where other forceps have failed. In pos- 
terior occiput; unless rotation can occur, very complete flexion is 
necessary. 

Experience has caused me to beheve that forceps should not be 
applied in any case without keeping in mind the necessity for axis- 




Fig. 93. 



-Occipital presentation: the forceps placed upon the sides of the child's 
head (Farabeuf and Varnier). 



traction. Even when the head is upon the pelvic floor it is often neces- 
sary to make several tractions downward and backward to complete 
rotation before bringing the occiput upward beneath the pubes. It 
is our rule always to use forceps with axis-traction appliances, and in 
the majority of cases the Simpson forceps, with tapes, proves most 
efficient. For prolonged and difficult traction at the brim of the pel- 



DELIVERY JU' FOKCEPS 



171 



vis, if the iiistruinciit could he i)ut iii)oii the sides of the head, the 
Tarnier forceps might be chosen. 

The Application of the Forceps to the Presenting Part. — The for- 
ceps is used in the great majority of cases upon the fetal head. Where 
the breech does not descend, the Tarnier has been applied over the 
trochanters, fastened as securely as possible, and traction made in 
the axis of the pelvis (Fig. 92). There is danger of slipping, however, 
when the forceps is applied to the breech, and for this reason this 
maneuver is rarely })ractised. 

Every effort should be made to place the forceps upon the sides 
of the fetal head over the parietal bones (Figs. 93 and 94). Mod- 




Fig. 94. — Forceps applied to the sides of the fetal head (Kerr). 



erate pressure in this position does no harm to the cranium or its 
contents, flexion or extension is secured most readily, and the ap- 
plication may be said to be a normal and rational one. The appli- 
cation of the forceps over the forehead and occiput should not be 
[practised, injury is inevitable, compression of the head produces 
increase in the biparietal diameter, which in complicated cases must 
cause additional difficulty. It is, however, sometimes impossible to 
apply the forceps to the sides of the head accurately, then the instru- 
ment should be applied at the extremities of the oblique diameters 
at the pelvic brim, and traction thus made until the head is well in 



172 OPERATIVE OBSTETRICS 

the pelvic cavity and the blades can be rotated to the sides of the 





Fig. 95. — Oblique grasp of the head by forceps. shoT\-ing one blade over the face 

(Kerr). 




Fig. 96. — Oblique grasp of the head by forceps, shoT\-ing one blade over the occiput 

(Kerr). 

cranium. In face presentation the blades would naturally lie along 
the sides of the face near the malar portions (Figs. 98 and 99). Pres- 



DKLIVEUV ]}V FOUCEPS 



173 




Fig. 97. — One blade of the forceps over the face, the other over the occiput (Kerr). 




Fig. 98. — Face presentation: the forceps applied to the sides of the head (Farabeuf 

and Varnier). 



174 



OPERATIVE OBSTETRICS 



sure thus applied would cause little or no injury and extension would 
be favored by the appUcation. 

Dangerous Applications of the Forceps. — When the head is im- 
pacted transversely at the pelvic brim, with rotation downward of 
one parietal bone, the appUcation of forceps is often undertaken,, 
usually with disastrous results. It is difficult in these cases to get 
the instrument applied in such a manner that it will not slip, and 
traction wedges the head more firmly into its vicious position. In 
brow presentation, forceps application is similarly useless and in- 




Fig. 99. — Forceps in face presentation (Kerr). 

jurious. In face presentation, with posterior rotation of the chin,, 
the use of the forceps is usually injurious; very rarely, if the head 
be small and not impacted, it may be dislodged by the forceps and 
ultimately brought under the pubes. 

The Repeated Application of the Forceps. — Where labor stops 
early in the expulsive stage, the presenting part not rotating, it may 
be necessary to apply the forceps, bringing the head down upon the 
pelvic floor to secure rotation, then removing them, and re-applying 
them for final deHver}^ Although each manipulation is a disad- 
vantage to mother and child, this practice in skilled hands produces. 



DELIVERY BY FORCEPS 



175 



good results and can be employed when necessary. If axis-traction 
be employed, it is less often necessary than in its absence. Simp- 
sou's forceps is especially designed to permit essentially frequent 




Fig. 100. — Forceps in face presentation . Bunim). 




Fig. 101. — Forceps in persistent occipitoposterior position of vertex TKerr). 



application of the forceps without removing the instrument from the 
birth-canal. 

In cases where rotation is absent and the operator finds great 



176 



OPERATIVE OBSTETRICS 



difficulty in applying the forceps to the sides of the head, he may 
follow an old rule, and insert the instrument along the sides of the 
pelvic cavity. Usually the instrument is inserted in an anteropos- 




Fig. 102. — Delivery by forceps with the occiput posterior (Farabeuf and Varnier). 

terior direction and not obliquely. The head is then grasped suffi- 
ciently firmly to prevent the forceps from slipping, and traction is 
made in the axis of the birth-canal; between each traction the blades 




Fig. 103. — Delivery by forceps with the occiput posterior (Farabeuf and Varnier). 



are separated, the grasp upon the head relaxed, and the head allowed 
to rotate within the forceps. Under this manipulation the head will 
gradually fit itself into the grasp of the forceps, and at the moment 



DKMVKKV in' FOHCKTS 



177 



of clclivery the iiistruniriit will usually be found at the sides of the 
child's head. 

Rotation With the Forceps. — With the instruments most com- 
monly em})loyed it is a dangerous procedure to gras}) the head if the 
forcei)s be rotated in the grasp of the operator. The narrow sohd- 
blacU^l forceps is, however, intended for this use. It is apphed 
midcv complete anesthesia, the position of the child being first care- 
fully mapped out by })alpation and auscultation. The position of 
the back should be clearly kept in mind. The instrument is then 
applied to the sides of the head, and gentle and intermittent rota- 
tion of the head is made in such a position as to bring the occiput 




Fig. 104. — Delivery by forceps with the occiput posterior (Farabeuf and Varnier). 

toward the side of the pelvis toward which the back is directed. 
When anterior rotation is sufficiently advanced to permit a further 
application of the forceps, the narrow-bladed forceps is removed, 
and may be, if desired, re-applied to the child's head. At the end 
of the first application ^^•ith the narrow-bladed forceps the extrem- 
ities of the cephalic portion of the blades would be directed back- 
ward, a position unfavorable for delivery over the pelvic floor. After 
rotation has been partially or completely accomplished, the instru- 
ment should be removed and again re-applied, and used in the ordi- 
nary mann(^r to complete delivery. In skilful hands this procedure 
is attended with little danger and considerable success. With the 
ordinary forceps it is safer to make intermittent traction in the axis 

12 



178 OPERATIVE OBSTETRICS 

of the biith-canal. relaxing the gTasp of the instniment between 
contractions: or to bring the head strongly down upon the pelvic 
floor, removing the forceps, and allowing the patient, if possible, to 
bring about rotation by the action of the tuerine and abdominal 
muscles. 

In all cases where rotation is deficient, the effort should be made 
to secure stifScient anterior turning with the hand to enable the 
operator to make a satisfactory forceps appHcation. Under siu- 
gical anesthesia with ether the operator should introduce the hand, 
accurately map oiu the position of the head, and gTasp the head, 
endeavoring to rotate it so that the occiput turns toward that side 
toward which the back is directed. Should tliis manipulation excite 
pain, he should hold the head firmly and wait for the pain to siil^- 
side. In almost aU cases the head can be rotated stifficiently to 
allow the appHcation of the forceps to the sides of the head. If 
the occiput can be carried in front of the median Ime of the pel- 
vis and axis-traction made, anterior rotation will usually occur. 
Care must be taken that this manipulation is practised under com- 
plete anesthesia, as otherwise danger of tuerine rupture might be 
present. 

The Function of the Forceps. — The forceps is a tractor only; 
it is not to be used to compress the head, and under ordinary cir- 
cumstances it is not a rotator. If it is desired to lessen the size of 
the cranium, this can be done more safely l^y craniotomy. If it is 
desired to rotate the head, tliis is best accomplished by the hand: 
should the hand not succeed, the sohd-bladed forceps maybeappHed. 
The forceps supplements the expulsive action of the uterus and 
abdominal muscles. If these functions of the instrument be kept 
clearly in mind, it will not be employed to drag a fetus through a 
contracted pelvis, fracturing its bones and destroying its Ufe: nor to 
forcibly rotate a large impacted head, nor, by leverage, to pry an 
impacted head loose from the mother's swollen tissues. Yet these 
injm*ious mistakes have been made in the application of the forceps. 

The Indications for Forceps DeHvery. — The forceps is the most 



DELIVERY BY FORCEPS 179 

commonly used instrunuuit of surgery, th(^ most fret^uently abiiscnl, 
in safe hands the safest, and in incompetent hands the most dangc^r- 
ous and bloody. It is to be used to save the lives and health of 
mother and child. 

On the side of the mother, its most common indication is the 
failure of her expulsive efforts from threatened exhaustion. Usually 
the mother's nervous energy fails because of the sufferings of labor, 
her inability to sleep, to bear pain, to take nourishment. In some 
cases the head is brought down upon the pelvic floor when the resist- 
ance of the pelvic floor, with the added suffering which pressure 
produces, causes labor to cease. The forceps is properly applied 
for conditions which require prompt delivery in the interests of the 
mother. Aside from threatened exhaustion or eclampsia, if condi- 
tions are favorable for vaginal delivery, signs of concealed hemor- 
rhage developing during labor, the sudden death of the mother 
just before delivery may require the use of forceps. In other cases 
it might be possible for the mother to deliver herself without assist- 
ance, but her suffering would be so great, convulsive, and expulsive 
pain would cause such laceration that it will spare her suffering and 
injury if she be completely anesthetized and delivered by forceps. 

Danger to the child justifies the use of forceps. Prolapse of the 
cord, which cannot be replaced, compression of the cord about the 
child's neck, long-continued labor with birth pressure, rise in tem- 
perature in the mother, indicating some infection which may attack 
the child, and fetal movements and heart sounds growing weaker, 
indicate prompt delivery. 

Conditions Making Forceps Delivery Justifiable. — The head must 
have engaged in the pelvic brim and molded itself into the pelvic 
brim before the use of forceps is justifiable. It has been abundant^ 
shown that the use of forceps upon the head not engaged above 
the pelvis or but just beginning to enter the brim is followed by 
dangerous pressure, often by cranial and intracranial hemorrhage, 
and permanent injury to the nervous system. In many cases the 
child dies as the consequence. With other obstetric operations 



180 



OPERATIVE OBSTETRICS 



as successful as are now pubiotomy and Cesarean section, unless the 
child is to be deliberately sacrificed, the forceps should not be ap- 
plied to the head until engagement and molding have occurred. 
If it is proposed to sacrifice the child, craniotomy is safer for the 
mother than difficult forceps extraction, the head not being engaged. 
The operator should know that the pelvis is of sufficient size to 
permit the passage of the head. Engagement and molding is a prac- 
tical demonstration of this fact, so far as the upper pelvis is concerned; 




Fig. 105. — Forceps slipping from the unengaged head (Bumm), 

there may be, however, contraction at the pelvic outlet sufficiently 
great to destroy the fife of the child during its exit. Pelvimetry, 
then, should be practised before forceps extraction and the measure- 
ment of the outlet included. Pelvimetry should include palpation 
of the pelvic cavity, as well as measurement by the hand and the 
pelvimeter. For successful forceps operation the cervix must be 
dilated or readily dilatable to its full extent by the hand, the mem- 
branes should be ruptured before the instrument is applied, the 



DELIVERY BY FORCEPS 



181 



bladder of the paticuit ^should be completely emptied under anestlu^sia 
by the catheter, the rectum should have been emptied by injection, 
and aseptic and antiseptic precautions should be observed. A 
competent anesthetizc^r and assistant should be at hand, and the 
necessary appliances for checking hemorrhage, preventing infection, 
and repairing lacerations. If these conditions and surroundings 
cannot be commanded, a physician will do well to abstain from the 
application of forceps and summon competent aid. 




Fig. 106. — Forcep.s slipping from the unengaged head (Bumm). 

Contraindications for the Use of Forceps. — Failure of the head 
to engage and partially descend, brow presentation, parietal bone 
presentation, posterior rotation of the chin, a fetus complicated 
by a tumor or pathologic conditions making its delivery impossible, 
contraction at the pelvic outlet, stenosis of the vagina and pelvic 
floor, partial dilation of the cervix with infiltration with malignant 
or scar tissue, and the presence of a dead child in a contracted pelvis, 
form the principal contraindications for the use of forceps. The un- 



182 OPERATIVE OBSTETRICS 

ruptured condition of the fetal membranes is so easily remedied 
that it can scarcely be considered an essential condition. 

Technic of Forceps Delivery. — Forceps dehvery should not be 
attempted unless the operator is prepared not only to extract the 
child and empty the uterus, but to control hemorrhage, prevent in- 
fection, and repair lacerations. A less complete operation cannot 
be considered the satisfactory use of forceps. The skilful use of the 
forceps under surgical anesthesia not only does not predispose to 
laceration, but helps greatly to avoid it. After complete anesthesia 
the operator with the forceps has good control of the head, the pelvic 
floor and perineum are relaxed, and dehvery is effected at his pleasure. 
In patients, however, who require the apphcation of forceps, the 
vagina is often but partial^ dilated, the patient generally is poorly 
developed, and hence laceration often occurs in these cases. 

The forceps should be prepared for use by sterilization by boil- 
ing. If the instrument be boiled in 1 per cent, lysol for twenty 
minutes it is sterile, and also sufficiently lubricated to permit its easy 
introduction. The operator should not only prepare the forceps, 
but instruments for packing the womb with gauze, and for the repair 
of lacerations. If the case promises to be difficult, it may be weU to 
have more than one kind of forceps ready; thus, Tarnier's and Simp- 
son's might both be in readiness. 

A patient is prepared for the use of forceps by shaving or trim- 
ming away the hair upon the external parts, thoroughly wasliing the 
external parts with soap and water, then with sterile water, then 
with bichlorid of mercury solution (1:2000). The rectum should 
have been thorough^ emptied by a copious enema. The patient 
should be catheterized only under ether and relaxed, as the bladder 
can then be most efficiently emptied. If the head has partly 
descended, it may be necessary to make pressure through the vagina 
upon the head in order to introduce the catheter, as the urethra may 
be pressed upon by the presenting part. 

The patient is placed in the dorsal position upon a high bed or 
table, the thighs supported and rotated outward by a sling or by 



DKMVEHV HY FORCEPS 183 

assistants. \\'e have found the use of a sheet folded in the longest 
way especialh' advantageous in separating the lower extremities. The 
sheet is plaeed beliind the patient's nc^ck and over the shoukh^rs, the 
legs and thighs are flexed, and the ends of the sheet are tied about the 
leg over the external aspect just below the knee. The lower extrem- 
ities are then flexed and rotated sUghtly outward. The sheet can be 
readily adapted for this purpose, as it is clean, simple, and easy to 
ap})ly. In difficult cases the limbs should be separated by an assistant, 
who can flex or extend the thighs as the operator may desire. The 
lower extremities and abdomen of the patient should be co^'ercd by 
sterile linen, and we have found a pair of larse stockings, terminating 
in a small square sheet, exceedingly useful for this purpose. This is 
sterilized before application, cannot become disarranged during deliv- 
ery, and is thoroughly efficient. In uninfected patients, if the head is 
not low upon the pelvic floor, a copious douche of lysol 1 per cent.) 
should be given before forceps extraction. If the head is so low that 
the mouth and eyes of the child may be entered by the fluid, the vagina 
should be gently cleansed with cotton sponges dipped in antiseptic 
solution. 

At the time of apphcation the patient should be completely anes- 
thetized by ether and in a thoroughly satisfactory condition. She 
should be under the charge of a competent anesthetizer, who will 
entirely relieve the obstetrician from anxiety concerning her safety. 
The anesthetizer should also be prepared to stimulate uterine contrac- 
tions when desired. Under antiseptic precautions the operator 
should then, with a gloved hand, palpate the head with the entire sur- 
face of the hand and map out its location and its relative position in 
the pelvis. The importance of this deliberate palpation of the head 
before forceps dehvery cannot be too strongly emphasized. It is 
not sufl&cient simply to introduce one or two fingers before intro- 
ducing the forceps. While palpating the head, if rotation is defi- 
cient, the operator should grasp the head and endeavor to secure a 
more favorable position. As most operators are right-handed, the 
right hand is often employed for examinations. When the head is 



184 



OPERATIVE OBSTETRICS 



in a favorable position, if the cervix is not satisfactorily dilated, the 
operator may dilate it further with the hand, if possible, carry the an- 
terior lip of the cervix over the occiput, and release it from pressure 
between the pelvis and the head. It will do much to prevent lacera- 
tion of the cervix if the head is out of the cervix before the forceps 
is applied. 




'£F-' 




Fig. 107. — Forceps delivery: introducing the left blade of Simpson's forceps 

with tapes. 



With the right hand between the pelvis and the head, the left 
blade of the forceps, grasped at its middle by the left hand, is intro- 
duced along the palmar surface of the operator's right hand. For 
introduction the blade should be held parallel with Poupart's liga- 
ment on the side opposite the head, the cephalic portion raised upon 
the thumb of the hand whose fingers are inserted, and allowed to glide 



DELlVHin BY FORCEPS 



185 



into place by a gentle and rotary motion. If the conditions are favor- 
able, it fits easily upon the fetal head. This blade should be held 
in position by an assistant while the operator introduces the left 
hand at the right side of the mother's pelvis, and inserts the right 
blade in a similar manner. This is usually more difficult of inser- 
tion than the left, because the left blade is somewhat in the wav and 




Fig. 108. — Introducing the right blade of Simpson's forceps vriih tapes. 



the available space is less. Especial care should be taken to insert 
the right blade properly and to fit it accurately upon the head. With 
the blades thus apphed, a gentle effort should be made to lock them; 
if they are accurately api:)hed the forceps locks itself, if not, the 
blades may be shifted slightly until they lock without undue pressure. 
Before making traction the operator should examine thoroughly 
to see that the blades are ]:>roperly applied, and that no maternal 



186 OPERATIVE OBSTETRICS 

tissue is included in their grasp. He should also determine how 
tightly they are fitting upon the child's head. 

Traction should be made, if possible, during uterine contrac- 
tions. The neglect to observe this precaution is sometimes fol- 
lowed by severe hemorrhage. When the operator is ready, the anes- 
thetizer should rub the uterus until the contraction begins. The 
operator may then make traction, and the endeavor should be to 
continue the uterine contraction during the operator's effort. In 
almost all cases traction should first be downward and backward, 
even if the head is upon the pelvic floor, to secure complete flexion 
or extension, and, if possible, to arouse the action of the pelvic floor. 
Traction should be intermittent if Simpson's forceps be used, the 
operator relaxing the blades between the tractions to reheve pres- 
sure upon the fetal head. When the pelvic floor has been reached, 
rotation will usually have occurred, if already not present. Trac- 
tion should be in the axis of the birth-canal, which will best accom- 
plish rotation. In delivering the head over the pelvic floor the opera- 
tor must remember that while the fine of force is upward and for- 
ward, this line does not impinge against the pubes. If the head be 
drawn too strongly toward the pubic bone, laceration of the anterior 
segment of the pelvic floor may be considerable. In very difficult 
cases the urethra has been ruptured and the pubic bones separated. 
The aim of traction should be to cause the occiput to engage normally 
under the pubes. When this has been accomplished, the occiput 
being sufficiently advanced to permit extension, the face and chin 
are cautiously raised over the pelvic floor. During this maneuver 
complete anesthesia is necessary. The passage of the head over 
the pelvic floor may cause great pain, the muscles will be thrown 
into spasm, the patient will struggle, and severe laceration may occur. 
If complete relaxation be present, laceration is less and suffering 
is prevented. 

During the delivery of the head the operator may grasp the 
forceps handles with one hand, and with the other apply a compress 
of gauze, wrung out of hot bichlorid solution (1 :4000), across the 



DELIVERY BY FORCEPS 



187 



pelvic floor at the region of the auu<. comiiletely covering the anus 
at the moment of expulsion (Fig. IIU;. This will assist somewhat 
in preventing laceration, and will also prevent the contents of the 
bowel from escaping and infecting lacerated surfaces. If. as the 
head is about to emerge, the operator sees that serious laceration is 
inevitable, he may prefer to perform episiotom\-. Tliis is done b\' 




Fig. 109- — Deliver^.- %^ith .Simpson s forceps and tapes: pulling downward and back- 
ward with the tapes. 



inserting a blimt-pouited bistoury* or a blunt-pointed pair of scissors 
at one side of the sphincter of the vagina at the junction of the 
upper two-thiixis and the lower one-thiid. A cut is made outward 
and shghtly downward of not more than IJ inches. If necessari*. 
episiotomy may Ix^ bilateral. The pehic floor and perinetim in- 
stantly retract and the deUvery of the head is readily accompUshed. 



188 



OPERATIVE OBSTETRICS 



As soon as the head is delivered, the anesthetic should be removed 
from the patient's face. A few moments' delay may be utilized in 
cleansing the mouth and eyes of the child, and if the cord is about 

the neck or pinched in the pelvis the cord should be genth' drawn 
upon and loosened. After a few moment? the uterus should be rubbed 
and stimulated to contraction and the child broudit down until the 




Fig. 110. — Forceps deliven- extraction of the head over the pelvic floor. 



operator has access to the shoulders. Then, with the fingers in the 
posterior shoulder, making traction downward and backward, if the 
shoulders have not alread}^ engaged beneath the pubic bone, they 
should be brought down. Anesthesia should again be continued 
and the shoulders delivered, the posterior shoulder first and then the 
anterior, by causing lateral flexion of the trunk. It is desirable to 



DELIVERY BY FORCEPS 189 

control the i)aticnt during the delivery of the shoulders, as lacerations 
by the child's elbow sometimes happen. 




Fig. 111. — Extraction of the head T\-ith forceps protecting the pelvic floor (Nagel). 

AMien the child has been delivered, anesthesia should be sus- 
pended during the delivery of the placenta. 

Variations in Forceps Operations. — AMiile we have described the 



190 



OPERATIVE OBSTETRICS 




Fig. 112. — The use of the forceps with the patient in tlie left lateral posture. Intro- 
duction of the lower or left blade (Kerr). 




Fig. 113. — Delivery of the patient in tlie left lateral posture. Introduction of the 
right or upper blade with the axis-traction forceps (Kerr). 



usual application and use of the forceps, experiences may arise 
which may require a very different procedure. 

Many operators prefer to place the patient upon her side for 



DELIVERY BY FOKCErS 



191 




Fig. 114. — Delivery of the patient with axis-traction forceps in the left lateral 
position. Rotation of the right or upper blade in the hollow of the sacrum to the 
child's head (Kerr). 





^^^Bi^^^^^^^^^^l 




i 


Ajl.^^ 


"^^^m 



Fig. 1 15. — Delivery of the patient in the left lateral posture with the axis-traction 
forceps. The blades are locked, the traction rod of the right blade in front now 
carried back beside tlie left one (Kerr). 



a forceps delivery. She is thus in a position very advantage- 
ous for traction downward and backward, the hips being at the 



192 



OPERATIVE OBSTETRICS 




i 

Fig. 116. — Deliver^' of the patient in the left lateral posture ^'hh axis-traction forceps. 
The forceps applied and locked (^Kerr). 




Fig. 117. — Delivery by axis-traction forceps in the left lateral posture : traction do^Mi- 
ward and backward ^^-ith the traction rods (Kerr). 



edge of the bed or table, the perineum and pelvic floor are free 
to dilate, and in the high application of the forceps at the pelvic 



DELIVERY HV FORCEPS 



193 



brim this position has much to coinmcncl it. Its practice is less often 
employed in America than it might be. 

A more efficient procedure, where the head descends through the 
pelvic brim with difficulty, is the use of Mercurio's or Walcher's posi- 
tion (Fig. 119). In this the patient is held by two strong assistants 
and her sacrum raised upon the edge of a table which has been 
thoroughly padded to prevent injury. The lower extremities, hang 
freelv mobile and are rotated outward. The bladder must be emptied 




Fig. 118. — Delivery of the patient in the left lateral posture with axis-traction 
forceps, the head passing over the pelvic floor and perineum (Kerr). 

with especial care before the forceps is applied. The operator then 
sits beneath the edge of the bed or table in such a position that 
traction is made directly downward and backward. The forceps is 
then applied as accurately as possible to the sides of the head, and 
traction made downward and backward until the pelvic floor has been 
reached. When the head is well upon the pelvic floor and rotation 
has been effected, the patient may be drawn upward and backward 
upon the table, the lower extremities flexed, and delivery completed. 

13 



194 



OPERATIVE OBSTETRICS 



After symphysiotomy and pubiotomy the forceps is applied to 
the head as in ordinary cases. In making traction especial care must 
be taken to avoid bringing the head against the cut ends of the pubic 
bone; the pelvic floor and perineum may be sacrificed, if necessary, to 
avoid this accident. Laceration of the anterior vaginal wall after 
pubiotomy or symphysiotomy is a serious accident, often followed 




Fig. 119. — Using the axis-traction forceps with the patient in Walcher's position 

(Kerr). 



by hemorrhage and infection. The same caution applies to the 
use of forceps after vaginal Cesarean section, when the lower uterine 
segment may be injured if traction is made in an improper manner. 
This is also true of the use of forceps after suprasymphyseal extra- 
peritoneal section. 

The High, Middle, and Low Application of Forceps. — Writers 



DELIVERY BY FORCEPS 



195 



often attempt to distinguish various forceps applications by ref- 
erence to the position of the fetal head. This distinction is of more 
theoretical than practical value. The same principles of applica- 
tion, the same necessity for axis-traction, the same instruments and 
appliances are necessary for all forceps applications. As other 
operations have excluded the application of the forceps to the head 
which is not engaged, it is best, we think, to consider forceps applica- 




Fig. 120. — Ineffectual application of the blades of the forceps to the sides of the 
child's head without flexion (Farabeuf and Varnier). 



tions with reference to the proper use of the instrument, and not to 
the position of the fetal head. 

The Forceps in Deficient Rotation. — Here, as w^e have indicated, 
under complete anesthesia the operator's first effort is to rotate the 
head sufficiently with the hand to get the occiput in front of the 
median line, when the forceps may be applied to the sides of the 
child's head. Axis-traction will bring the forceps and the head to- 
gether upon the pelvic floor, and then into the median line. In diffi- 
cult cases, where the forceps cannot be placed upon the sides of the 



196 



OPERATIVE OBSTETRICS 



head, Simpson's forceps should be apphed in the oblique pelvic 
diameter, traction made in the axis of the pelvis, the grasp of the 
blades being relaxed between contractions, and the head encouraged 
to rotate within the forceps blades. 




Fig. 121 



-Forceps in first position of vertex, ^-ith incomplete rotation (Bumm). 
Naegele forceps. 



In some cases the occiput, much to the disappointment of the 
operator, will rotate directly backward instead of forward. In 
these cases some advise the abandonment of the use of the forceps, 
the pushing of the head upward, and the completion of labor by 



DELIVERY BY FORCEPS 



197 



version. If the head is easily dislodged, this may be done; if it is 
firnil}' engaged upon the pelvic floor, such an effoi-t might cause 
rupture of the utc^rus. The occi})ut can be deliven^d posteriorly if 
extreme flexion can be maintained and if the pelvis and the child's 




Fig. 122. — Forceps in second position of vertex, with incomplete rotation (Bumm). 

Naegele forceps. 

head are of proportionate size. Considerable laceration of the pelvic 
floor is inevitable, although we have rarely seen it extend into the 
rectum. The forceps being accurately applied to the sides of the 
child's head, traction is made slightly downward and backward, 
the occiput pressing strongly into the pelvic floor until the fore- 



198 OPERATIVE OBSTETRICS 

head of the child engages beneath the pubes. The operator may 
then endeavor to cautiously raise the occiput from the pelvic floor, 
while the forehead pivots beneath the pubic bone. It may be 
necessary to loosen the grasp of the forceps, depress the handles, and 
take a slightly different hold upon the fetal head. If this cannot 



Fig. 123. — Forceps obliquely over the head, first position of vertex, with incom- 
plete rotation (Bumm). Naegele forceps. 

be accomplished, traction must again be resumed until the head can 
thus be delivered. Complete laceration of the perineum and pelvic 
floor may be avoided by surgical anesthesia, by securing extreme 
flexion of the head while passing over the pelvic floor, and by uni- 
lateral or bilateral episiotomy. 

Complications and Injuries Caused by the Forceps. — It may 



DKLIVEKY BY FORCEPS 109 

seem incredible that an educated i)hysician would attemj)! to drag 
the fetal head with the obstetric forceps through a pelvis too small 
for it. Yet those who see cases brouglit into hospitals and who 
have a consultation practice will admit with rc^gret that such is the 
case. The simple rule of }n"actice which asserts that after a reasonable 



Fig. 124. — Forceps obliquely over the head in second position of vertex, with in- 
complete rotation (Biunm). 

time, the head not descending, it must be pulled down, and that if 
one physician cannot pull it down, two or more can, is sure at some 
time to bring its follower into an obstetric disaster. It may be too 
much to expect the general practitioner to know and practice pel- 
vimetry or for the recent graduate to provide himself with a pel- 
vimeter. But recent graduates are taught to recognize engagement 



200 



OPERATIVE OBSTETRICS 



of the fetal head, and general practitioners should have learned the 
same lesson. It would be better for the patient if no attempt be 
made to deliver and the child die than to have forcible attempts at 
delivery with great disproportion. Those who urge that if the pelvis 
be accurately measured and found to be normal, the head, though 




Fig. 125. — Forceps in posterior rotation of the occiput (Bumm). 

even not engaged, may be grasped by the forceps and safely delivered,, 
omit one important factor in the problem. We have as yet no 
reliable and accurate method for measuring the fetal head within 
the womb. Our only efficient and reliable test is the presence of en- 
gagement and molding; if this be absent, efforts at delivery by trac- 



DELIVERY BY FORCEPS 



201 



tion are purely experimental. The lea^t injury wliich can follow such 
efforts is damage to the child's nervous system, or its death from 
the exercise of pressure, while the mother may escape with more 
or less laceration. 

Separation of the symphysis pubis, laceration of the urethra and 
anterior segment of the pelvic floor, laceration of the posterior seg- 




Fig. 126. — Examining the torn cenix drawn downward for repair. 



ment and opening of the posterior vaginal cul-de-sac into the peri- 
toneal cavity, may follow the improper use of the forceps. The 
T\Titer had occasion to deliver a woman by aMominal section into 
whose abdominal cavity a physician had thrust a blade of a Tarnier 
forceps in the effort to apply the instrument above the pelvic brim. 
The rent, mea.sured through the aMomen. admitted four fingers, and 



202 OPERATIVE OBSTETRICS 

was successfully closed from above. The slipping of the forceps 
may cause severe and cutting lacerations, and the violent use of a 
poor instrument may break the forceps, leaving a portion of the 
forceps within the womb. The forceps may be applied over the 
unruptured membranes and traction made, partially or completely 
separating the placenta, followed by violent hemorrhage. A loop of 
cord may be pinched by the forceps, causing the death of the child. 
In old primiparse, or in patients who have previously sustained injury 
to the coccyx, delivery by the forceps may break the coccyx at its 
junction with the sacrum. This may produce great distress during 
the patient's convalescence. It can be readily understood that the 
use of the forceps offers unusual opportunities for the conveyance of 
septic infection; hence, our best efforts are demanded to make the 
use of the instrument safe for mother and child. 

Injuries to the Child Caused by the Forceps. — Facial paralysis 
from pressure upon the facial nerves not uncommonly occurs. Unless 
pressure has been severe, recovery shortly follows. Fractures of 
the cranial bones with intracranial bleeding are not uncommon after 
violent delivery through a contracted pelvis. Bruises and wounds 
of the scalp and abrasions upon the skin of the face may occur in 
difficult forceps operations in skilful hands. In the writer's experi- 
ence, a patient having a contracted pelvis had repeated and fruitless 
€fforts at forceps dehvery made by her attending physician. When 
admitted to a hospital it was necessary to dehver her by abdominal 
section. The child's face was badly bruised and swollen, especially 
in the region of the orbits and over one eye. The loss of sight in this 
eye subsequently occurred through rupture of some of the membranes 
of the eye and the escape of the media. Direct injury to tlie eye 
by forceps is unusual and can only occur after severe and indis- 
criminate traction. In applying the forceps to the breech of the 
child, slipping or improper application might cause injury to the 
genital organs, or wounding and bruising of the bladder might occur 
if the forceps be improperly applied. In applying the forceps to the 
after-coming head the face is often bruised during forcible extrac- 



DELIVKRY BY FORCETS 203 

tion over the pelvic floor. The improper appUcation of the instru- 
ment over the occiput and face frecjuently causes s(^vere wounds. 

The Frequency and Results of Forceps Operations. — It is impos- 
sible to estimate accurately the frequency of forceps operations, 
as the necessity for their use depends so much upon the nervous 
condition of the patient. In large European clinics, filled with 
stolid peasant women, exhaustion is comparatively rare. With 
American women, illustrating in varying degrees the degenerating 
influence of luxury, the use of the forceps is very common. It is 
in cases where nervous exhaustion must be avoided and the patient's 
strength strongly conserved in every way that the use of the forceps 
is very successful. Improperly applied and without proper anti- 
septic precautions in these cases the forceps may cause unnecessary 
laceration and tend to make the patient a lasting invalid. 

The results of the use of the forceps depend very largely upon 
the skill and technic of the operator. Thus, it is possible for a skil- 
ful and careful obstetrician to use the forceps for years without mater- 
nal mortality resulting from the instrument. On the other hand, the 
improper use of forceps may be followed by double mortality. It 
must be understood that, in normal proportion between mother and 
child, in skilful hands the use of the forceps has no maternal mor- 
tality and very slight morbidity. In 100 cases of high application 
of the forceps, Rimmen^ had no maternal mortality which could be 
ascribed to the operation itself. Deaths occurred from eclampsia 
developing before the operation; 81 per cent, of these patients had 
a normal puerperal period, while 6 per cent, had compHcated recover}^; 
5 had localized infection; 3, exudate in the pelvis; 1, cystitis; 1, throm- 
bosis. The puerperal period was free from fever in one-half of the 
cases, while three-eighths had a temperature rising to 104° F., one- 
eighth reaching above 104° F. Injuries resulting from the high ap- 
pUcation of the forceps were : lacerations of the pelvic floor and peri- 
neum, laceration of the vagina extending to the pelvic bones in 1 
case, deep laceration of the cervix in 1, rectovaginal fistula in 1, 

1 Monatsschrift f. Geb. u. Gyn., Band 25, Heft 2, 1907. 



204 OPERATIVE OBSTETRICS 

paralysis of the perineal nerve in 1, and fistula between the ureter 
and bladder and vagina in 1. Of the 100 children, 69 were dis- 
charged in good condition. The mortality among the children was 
31 per cent. Many of these were in bad condition before operation 
was undertaken; 12 children perished during delivery, and 10 after. 
Among these the umbihcal cord was injured twice. Among the cases 
in which the head was molded before the application of forceps the 
fetal mortality was 11 per cent. Where the forceps was applied to 
the head not molded the mortality was 36 per cent. The children 
surviving suffered from pressure upon the parietal bone in 1 case, 
pressure and indentation of the forehead in 3, fracture of the cranium 
in 2, and the formation of hematoma in 1 . In the 100 cases the maternal 
mortality from the operation was nil; 16 per cent, of the mothers had 
prolonged puerperal periods with fever; 7 of the mothers had lacera- 
tions of considerable extent. Thirty-one per cent, of the children 
perished, and 10 per cent, of the surviving children sustained con- 
siderable injury. 

In the clinic at Basle, in 10,913 cases of labor, the forceps was 
applied in 3.27 per cent, of cases. Among these, 78.3 per cent, 
were primiparse. The most usual indication was threatened exhaus- 
tion. The maternal mortality was .97 of 1 per cent., from fatty 
heart, eclampsia, and rupture of the uterus. In 8 cases there was 
severe infection, and mild infection in 36 per cent. The fetal mor- 
tality was 10.5 per cent, from intracranial hemorrhage, and in a con- 
siderable number of cases there was decided laceration of the child's 
scalp. In the Dresden clinic, Leisewitz,^ in 27,238 labors, found 2.55 
per cent, forceps apphcations. The most prevalent indication was 
danger to the child from birth pressure; next, threatened exhaustion; 
and then in the interests of mother and child. When the fetal heart 
sounds dropped to 80 or 100, or rose above 160, with or without the 
escape of meconium, the forceps was used in the interests of the 
child. When the mother was becoming exhausted, with signs of 
interference in the fetal circulation, or fever in the mother with 

1 Arcliiv f. Gyn., Band 81, Heft 3, 1907. 



DI']LIVERY BY FORCEPS 205 

beginning asphyxia in the child, the forcei)s was appHcHl. In the 
mother's interest, eclampsia, nephritis, heart lesions, i)ulm()nary 
tuberculosis, threatened failure of uterine contractions, and rapidly 
increasing contraction-ring, premature rupture of the membranes, 
and hemorrhage, all furnished indications. The results in Conti- 
nental clinics show that the forceps is invariably used under favorable 
conditions where the interests of the child are threatened. There is 
considerable difference of opinion concerning its use for the mother 
only. In contracted pelves the forceps was most often applied in 
justominor or symmetrically contracted pelves. As regards the 
situation of the head in these operations, it was in the entrance of the 
pelvis or upper pelvis in 5.31 per cent.; in the pelvic cavity in 50.21 
per cent., and in the outlet of the pelvis in 4.45 per cent. The appli- 
cation of the forceps in the pelvic brim was made in contracted pelves 
where the head had engaged. The relative apphcation in the mothers 
was 79.5 per cent, in primiparse, the multiparse being 20.95 per cent. 
The mortality of the mothers from all causes was 3.21 per cent.; 
if eclampsia be excluded and forceps applications only considered, 
the mortality was reduced to .58 of 1 per cent. The fetal mortality 
was 15.63 per cent.; fractures and compression in 4.73 per cent., 
asphyxia in 6.59 per cent., and deaths from other causes developing 
soon after birth in 4.3 per cent. Under the most careful analysis 
fetal mortality was reduced to 10.68 per cent. Where the forceps 
was used in the interests of both mother and child the fetal mortality 
was 13.93 per cent. In this series the corrected fetal mortality was 
11.54 per cent. It is curious to observe that in normal pelves the 
fetal mortality w^as 14.28 per cent.; in 5.95 per cent, the improper 
use of the instrument was the cause of the mortality. When the 
pelvic outlet was contracted the fetal mortality was 8.5 per cent. 
The mother sustained injury requiring suture in 73.6 per cent. Among 
the children 5.45 per cent, had paralysis of the facial nerve; 1.15 per 
cent, had paralysis of a nerve plexus. 

That severe laceration can follow the high application of the 



206 OPERATIVE OBSTETRICS 

forceps is illustrated in a case of Puppel's/ The patient was a very 
large multipara, whose tlii*ee previous labors had terminated spon- 
taneously. In the fouith the head failed to descend and remained 
above the inlet of the pelvis. The child's heart sounds gi'ew weak 
and version was attempted, but failed. The patient was then placed 
in Walcher's position, the head pressed .strongly downward, and the 
forceps applied in the transverse diameter of the pelvis. The uterus 
contracted strongh', and with suprapubic pressure the child was 
dehvered in thirty minutes. The cord was about the neck and the 
child was asphyxiated, liut revived. The mother had no laceration 
in the cervix or perineum and the placenta was readily delivered. 
After dehvery the mine became bloody, the patient had pain on 
the right side above Poupart's ligament, with dulness on percussion, 
which grew worse, followed by collapse. She was taken to a hospital 
and after anesthesia an incision made over the right Poupart's Uga- 
ment. Veiy offensive urine escaped from the incision, with particles 
of gangrenous tis.sue. Laceration had occurred, wliich extended to 
the base of the bladder in front, and posteriorly to the posterior spine 
of the pehds. Death followed shorth^ after. Although a complete 
autopsy was impossible, it was found that the tissue outside the 
bladder at the sides of the pelvis had been lacerated, the bladder 
bruised, urine had extravasated, and infection ha<;l developed. In- 
jury had occurred during the forceps dehvery. made more easily pos- 
sible by Walcher's position. In prolonged labor the base of the 
bladder becomes intensely congested and severe pressure may cause 
necrosis and gangi'ene. 

The attempt to dehver the head at the peMc brim without 
uterine contractions is a dangerous procedure. The ^Titer- recalls 
the case of a stout, vigorous multipara, who. during a preceding 
pregnancy, had gone some time over the usual hmit of gestation. 
Labor was then induced by bougies and bags : the latter were applied 
at intervals for twenty-four hours, causng intense suffering. A 
difficult forceps delivery terminated in the birth of a child whose 

1 Monatsschrift f. Geb. u. Gvn., Band 25, Heft 4, 1907. 



DELIVERY BY FORCEPS 207 

cranium is permanently marked with an indentation caused by the 
forceps. In the following pregnancy the question arose as to what 
-hould be done with this patient. It was thought that the patient 
-hould be anesthetized with ether and that the head could be brought 
into the pelvic brim and delivere<:l with forceps, making an imme- 
diate deliver}* and avoiding the suffering and delay of induced labor. 
The pehis was ample in size, the position and presentation of the 
child normal y and the advice was given to allow the pregnancy to go 
on until the uterus acted spontaneously; if the head engaged, then to 
deliver with forceps under ether: if engagement did not occur, to per- 
form whatever operation might be necessary . 

This ad\'ice did not suit the impatient patient. Her family 
physician was persuaded to anesthetize her and to deliver with for- 
ceps. Diuing anesthesia she was seized with heart failiu-e from 
which she was revived with difficulty. The child was extracted with 
forceps as rapidly as passible, and was dead-bom through birth 
pressmre. 

In cases where the mother has had a painful experience in former 
labor, her apprehension may be so great that the coming confine- 
ment is viewed with horror. Any interference with the genital tract 
may be followed by shock, and this is especially apt to occur ia the 
absence of uterine contractions. Under complete anesthesia such 
patients should be deUvere<;l in that manner which causes least me- 
chanical injury and least distm-bance. 

The use of forceps in contracted pelvis is indicated under one 
condition only — labor must have developed sufficiently to cause 
engagement and beginning descent. When this has occiured, if the 
mother requires assistance, the forceps may be employed to advan- 
tage. Scheffzek^ gives the results of the apphcation of forceps in 
the clinic at Breslau. In 37 cases it was necessary to terminate 
labor with pubiotomy once. The mothers recovered, although the 
puerperal period in many was complicated by rise of temperatiu^ 
and by lacerations: 58 per cent, of the children lived and 42 per cent. 
*Archiv f. Gyn., Band SS, Heft 3, 1909. 



208 OPERATIVE OBSTETRICS 

perished. The application of the forceps below the pelvic brim was 
performed in 60 cases of contracted pelvis, 44 of whom were primiparse. 
There was no maternal mortahty in these cases. Among primip- 
arse there was fever during the puerperal period in 16 per cent. 
The moitality among the children was 15 per cent. This is very simi- 
lar to the reports of Peham (17.2 per cent.), Burger (11.6 per cent.), 
and Bloodwig and Savor (21.7 per cent.K 

Although the application of the forceps in face presentations is 
unusual, A'on Herff ^ has had favorable results. Jolly- lias also dehvered 
the fetus in face presentations successfully with forceps. He reports 
unsuccessful cases, where the head had not properly engaged, ^\ith 
posterior rotation, and would limit the use of the instrument in face 
presentations to faA^orable positions of the face. 

In comparison with other operations the skilful use of the forceps 
in selected cases is without maternal mortality, has a maternal mor- 
bidity of about 10 percent., and a fetal mortality of not less than 
10 per cent. In improperly selected cases, disregarding the absence 
of engagement and molding, the use of the forceps has a direct 
maternal mortality of from 3 to 5 per cent., a maternal morbidity 
of 20 to 30 per cent., and a fetal mortality of 30 to 50 per cent. 

Bibliography 

Forceps Deliveiy: Indications For 
Barta: Orvosi Hetiiap., Xo. 29, 1907. 
Boerma: Zentralblatt f. Gj^nakologie, Xo. 20, 1907. 
Brodhead: American Jom-nal of Obstetrics, May, 1904. 
Brown: Jomnal of Obstetrics and GynecologA' of the British Empire, 

p. 503, 1907. 
Demelin: Zentralblatt f. Gynakologie, Xo. 2, 1907. 
Eisenstein: Gyn. Rundschau, p. 650, 1907; Zentralblatt f. Gynakologie, 

Xo. 3. 1909. 
JoUy: Zentralblatt f. G}Tiakologie, No. 50, 1907. 
Jones: Journal of Obstetrics and Gynecology of the British Empire, 

Xovember, 1906. 
Klatscko: Zentralblatt f. Gynakologie. Xo. 21, 1909. 

^ Heger's Beitrage zur Geb. imd Gyn., Band 12, Heft 1, p. 1, 1907. 
- Zentralblatt f. Gyn., No. 50, 1907. 



DELIVEia li\ FOKCKl'S 209 

Kynoc'k: British Medical Journal. July 23, 1904. 

Lacky: Zeiitralblatt f. Gynakologie, \o. 47, 1909. 

Leisewitcli: Arcliiv f. Gynakologie, Bantl SI. 1907. 

McDonald: American Journal of Obstetrics, Feb., 1910. 

Muss: Monatsschrift f. Goburtsliiilfe und Gynakologie, Band 22, Heft 

1, 1905. 
Neumann: Zentralblatt f. Gynakologie, Xo. 10. 1900. 
Oskar: Zentralblatt f. Gynakologie. Xo. 3, p. 72, 1907. 
Popescul: Zentralblatt f. Gynakologie, Xo. 29, p. 90S,, 1907. 
Reed: Surgery, Gynecology, and Obstetrics, January, 1906, and June, 

1906. 
Riemann: Monatsschrift f. Geburtshulfe und GA'nakologie, Band 25, 

Heft 4, 1907. 
Simpson: Scottish Medical and Surgical Journal, December, 1900. 
Willson: Lancet, p. lOSS, 1909. 
Winckel: Zentralblatt f. Gynakologie, Xo. 48, 1903. 
Zangemeister : Zentralblatt f. Gynakologie, X'o. 20. 1908. 
Zernik: Zentralblatt f. Gynakologie, X'o. 47, 1909. 

Forceps Delivery: Complications and Injuries 
Bokelmann: Zentralblatt f. Gynakologie, X^o. 15, 1900. 
Iv}Tioch: British Medical Jom'nal, July, 1904. 
Leopold: Zentralblatt f. Gxmakologie, X'o. 16. 1902. 
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4, 1907. 
Ritter: Zentralblatt f. Gynakologie, Xo. 41. 1903. 
Savidge: American Journal of Obstetrics, August. 1905. 

Forceps Operations: Results of 
Baisch: Therapie cles engen Beckens, Leipzig, Georg. Thieme, 1907. 
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1, 1901. 
Discussion: Monatsschrift f. Geburtshulfe und Gynakologie. Band 22, 

Heft 4, 1905. 
Gans: Monatsschrift f. Geburtshulfe und Gynakologie, Band 27, Heft 

4, 1908. 
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25, 1907. 
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Kiistner: Zentralblatt f. Gynakologie, X'o. 37, 1907. 

14 



210 OPERATIVE OBSTETRICS 

Leisewitz : Archiv f . Gynakologie, Band 81, 1907. 

Leopold: Archiv f. Gynakologie, Band 81, 1907. 

Mehrmann: Zentralblatt f. Gynakologie, No. 31, 1907. 

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1907. 

VERSION 

By version is understood such alteration in the position of the 
fetus as enables the operator to clasp the body of the child for deliv- 
ery, or bring the long axis of the fetus parallel with that of the 
mother's birth-canal, and render deUvery possible. One of the 
oldest operations in obstetric surgery, version has been overshad- 
owed by operations requiring incision. The fact that it can be per- 
formed in emergencies by a physician without skilled assistants, 
that it gives the physician immediate control of the fetus, and that 
it is most useful in some of the most important comphcations of 
parturition, makes it especially valuable. 

Varieties of Version with Reference to the Fetus. — Version may 
be cephalic or podahc, as the upper or lower extremity is brought 
to the pelvic brim. With reference to the mother, version may be 
external, internal, or combined. 

By prophylactic version in contracted pelvis is understood 
version which brings the breech first through the pelvis, the after- 
coming head turning transversely at the pelvic brim. In a simple 
flat pelvis this position of the head is especially favorable for success- 
ful delivery. 

The Indications for Version. — The most obvious indication for 
version is an abnormal position of the fetus, which threatens rup- 
ture of the womb unless it be rectified. Shoulder presentation, 
transverse position, impaction of the fetus with great distention of 
the lower uterine segment, and threatened rupture, form the con- 
dition where, obviously, measures must be taken to alter the posi- 
tion of the fetus to avoid rupture of the womb. If the condition is 
just developing, it may be possible to perform version without 



VERSION 211 

enibryotoiiiy. But, if the stretching of the lower uterine segment 
is extreme and the uterus in tetanic contraction, embryotomy must 
first be clone and d(^liv(^ry efiected by version and extra(;tion. 

Prolapse of the cord, in which efTorts at reposition are not suc- 
cessful, is best treated by carrying the cord above the pelvic brim, 




Fig. 127. — Anterior rotation of the occiput by combined manipulation (Kerr). 

performing version, and proceeding to extraction. Hemorrhage from 
the various kinds of placenta prsevia can be controlled wdth the sac- 
rifice of the fetal life, by turning the child and using it as a plug. 
Positions of the fetal head which defeat efforts at forceps delivery, 
such as brow presentation, parietal bone presentation, posterior im- 
paction of the occiput, or face presentation, may often be termi- 



212 



OPERATIVE OBSTETRICS 



nated by version under deep anesthesia, followed by extraction. In 
labor in contracted pelves, version must be selected only in simple, 
flat pelves, when it is definitely known that the internal antero- 




Fig. 128. — Thorn's method for converting a face into a vertex presentation, 
arrows indicate the directions of pressure and traction (Kerr). 



The 



posterior diameter is at least 8.5 cm., and the head of the child not 
excessively large or hard. Aversion in justominor pelves, in funnel- 
shaped pelves, in highly rachitic pelves, and in the rarer forms is 



VERSION 213 

usually followed by fetal death and injury to tlu^ mother. In com- 
plex presentations, whert^ the use of forceps is ini})ossible and it is 
difficult to maj) out the fetus, delivery becoming necessary, version 
will give the best results. 

The Essentials for Successful Version and Preparation for the 
Operation. — For version and its adjunct, extraction, to be successful, 
the internal anteroposterior diameter of the pelvis must be at least 
8.5 cm. and the child not excessive in size. There must be no essen- 
tial contraction at the pelvic outlet. The uterus must not be in a 
highly tetanic condition. The urinary bladder must be thoroughly 
emptied by catheter, and the rectum by injection. If possible, a 
competent anesthetizer must be available. Aseptic and antiseptic 
precautions are imperative. 

Patients should be prepared for version by rendering the external 
parts aseptic as thoroughly as possible; the patient should be cath- 
eterized when anesthetized completely. Chloroform anesthesia 
should be emploj^ed during version. If the operator is to proceed 
no further, anesthesia may cease and labor allowed to go on spon- 
taneously. If extraction is to follow version as soon as possible, 
ether should be substituted for chloroform after version is complete. 
The patient should be, in most cases, in the dorsal position, with the 
lower extremities suitably separated. The tliighs should be flexed 
sufficiently upon the abdomen to relax the muscles at the pelvic brim. 
If external version is to be performed, it is not alwaj^s necessary to 
put the patient upon a table. If the operator expects to practice 
vaginal manipulation immediately after external version, a table 
or very high narrow bed will be necessary. A copious vaginal irriga- 
tion of 1 per cent, lysol should be given before internal or combined 
version is attempted. The operator should have in readiness in- 
struments and appliances for controlling hemorrhage, giving stinui- 
lation, and repairing lacerations. If extraction is to follow, the for- 
ceps and instruments for repairing lacerations, with apphances for 
resuscitation and care of the child must be provided, as danger- or 
injury to the child is considerable. 



^14 OPERATIVE OBSTETRICS 

External Version. — In patients who are not highly sensitive 
and nervous, in whom the fetus occupies an unfavorable position, 
or where the contour of the pelvis is such that it is desired to cause a 
different presentation, an attempt may be made to turn the fetus by 
external manipulation. If it is the purpose of the operator to in- 
stitute delivery immediately after, external version should not be 
undertaken until the cervix is partly dilated or dilatable. It is almost 
imperative that the membranes be unruptured. The patient should 
lie upon the back, with the thighs flexed, and if she be excitable, 
sensitive, or irritable, she should have transient anesthesia with 
chloroform. The operator should map out the fetus carefully by 
palpation and auscultation, and determine in which direction he 
wishes to turn the child. Placing his hands at the extremities of the 
fetal ovoid, he should endeavor to lift the fetus slightly away from 
the pelvic brim, and with one hand bring that extremity of the 
fetus to the brim which he desires to have enter, while with the 
other hand he carries the opposite extremity upward in the mother's 
abdomen. This is best accomplished by gentle intermittent efforts, 
pausing between them, and holding the fetus gently but firmly in its 
newly acquired position. If the membranes are unruptured, the 
fetus not excessive in size, and the muscular action of the mother 
controlled, it may thus be possible to turn the child in the manner 
desired. 

The Retention of the Child After External Version. — While one 
may succeed in turning the child, it is another matter to retain it in 
the desired position. Efforts have been made, by placing a long pad 
on each side of the abdomen, to prevent the fetus from returning to 
its undesired situation. A firm bandage has been applied over this 
pad, and the patient kept lying upon that side which would best 
facilitate descent and engagement. Unfortunately, these efforts 
are not always successful. 

If the fetus is to remain in its desired position after external 
version, the presenting part must be brought into the pelvic brim 
and the membranes ruptured, so that definite engagement and mold- 



VERSION 215 

iiig will develop. The cervix should at least be thoroughly softened 
and slightly dilated for this to occur. When these conditions are 
present the fetus will remain in its desired position. Aft(*r perform- 
ing external version, if the operator wishes to proceed to bring the 
patient into labor, he should dilate the cervix as thoroughly as the 
conditions will permit and then rupture the membranes. If the 
head enters the pelvis promptly, not all of the amniotic liquid will 
escape, and labor will develop with the fetus in the desired posi- 
tion. 

The advantages of external version are that, so far as the manip- 
ulation is concerned, it exposes the patient to no danger from infec- 
tion, and, with reasonable skill, there is little risk of injuring the 
child, the placenta, or the mother. Unfortunately, unless the 
operator is prepared to bring on labor immediately, the results of 
external version are so uncertain that it cannot be considered 
reliable. 

Combined Version. — Combined version, often described as Brax- 
ton-Hicks' method, consists in altering the position of the fetus by 
the fingers of one hand introduced within the vagina, aided by ma- 
nipulation with the external hand. 

Indications and Preparation for Combined Version. — Combined 
version is most often performed for placenta prst^via. Its object, in 
this condition, is to enable the operator to grasp a fetal leg, by trac- 
tion to bring the breech into the pelvic cavity, compressing the 
placenta against the pelvic wall and stopping hemorrhage. It is 
frequently not followed by extraction, and in placenta prsevia, as the 
life of the child is disregarded, its body is used as a plug. Com- 
bined version is also employed in cases where the cervix is partty 
dilated, where some condition arises requiring comparativety prompt 
delivery or necessitating pressure in the lower portion of the w^omb. 
Thus, in eclampsia, with partly dilated cervix, if the operator ruptures 
the membranes and brings down a leg of the fetus, convulsions will 
sometimes cease. 

To prepare a patient for combined version the usual antiseptic 



216 



OPERATIVE OBSTETRICS 



precautions for vaginal operation should be observed. Chloro- 
form should at first be employed, followed by ether if prolonged 
manipulations are desired; the patient should be carefully cathe- 
terized under complete anesthesia. With the patient upon her back, 
on a table or high narrow bed, the operator should introduce several 
fingers of one hand into the vagina and examine the cervix. He 



Attachment of 
placenta to lower J 
uterine segment ^ 




Fig. 129. — The breech as a tampon in placenta prsevia (Bumm). 



should dilate the cervix as far as possible with the fingers, avoiding 
at first rupture of the membranes. When he has accomplished as 
much as possible in this way, the fetus should be pressed gently 
downward into the pelvis and the membranes ruptured. At this 
moment the fingers are to be inserted as far as possible and an effort 
made to grasp one of the feet of the child. This may, at first, be im- 
possible, and the knee may be reached ; in other cases the arms pro- 



VERSION 217 

lapse and the o})erator can find with his fingers nothing but the 
head and upper extremities. The internal fingers should not be 
withdrawn, but the external hand should be placed ujx)n the abdo- 
men, the head pushed gently upward, and the lower extremities of 
the fetus pressed downward. With patience and gentle manipula- 
tions it is usually possible to cause the lower extremities to descend 
into the pelvic cavity, so that one or both feet can be grasped. When 
this has been accomplished, the breech should be brought into the 
pelvis and a noose of sterile gauze bandage placed about one foot, 
so that, if necessary, traction can be made at intervals without intro- 
ducing the fingers within the vagina. If extraction is not to follow, 
the vagina should be tamponed lightly with 10 per cent, iodoform 
gauze. Some prefer to attach a light weight to the noose around 
the fetal ankle to maintain constant pressure against the cervix, 
thus keeping the body of the child tightly applied to the sides of the 
pelvis. 

Combined Version for Shoulder Impaction. — In cases of shoulder 
presentation, if impaction threatens rupture, version may be performed 
to dislodge the shoulder and bring the head or breech into the pelvic 
brim. This manipulation requires good judgment, patience, and 
dexterity. The patient must be placed upon her back upon a bed 
or table, antiseptic precautions thoroughly made, the bladder com- 
pletely emptied under anesthesia, and chloroform given to complete 
relaxation. The position of the fetus being carefully mapped out, 
the operator introduces one hand within the vagina and, inserting 
the fingers in the axilla of the fetus, endeavors very gently to lift the 
shoulder up from the pelvic brim. The patient's thighs should be 
flexed during this maneuver to relax the muscles at the brim of the 
pelvis. The external hand should endeavor to dislodge the breech 
of the child from its position, and carry it gently upward and toward 
that side of the mother's abdomc^n upon which the head is resting. 
If the operator feels that he is moving the child, he will then attempt 
to raise the child sufficiently high to permit the head to present at 
the pelvic brim. He may often be greatly aided by intermittent 



218 



OPERATIVE OBSTETRICS 




Fig. 130. — Impacted shoulder presentation with prolapse of the arm (Chiara). 

manipulations by an assistant, who stands at the patient's side and 
endeavors to control the descent of the head. 



VERSION 



219 



Should this cft'ort fail, the operator may then try to cause the 
descent of the breech and the ascent of the head into the uterine 
cavity. The shoulder is then lifted directly upward and to one side 




Fig. 131. — Rupture of the utenis in its most usual location, showing the contrac- 
tion-ring and Bandl's groove or depression very strongly marked (XageP. 

of the promontory of the sacrum, the head is carried gently upward 
into the uterine cavity, and the breech thus allowed to drop do'^'n- 
ward into the pelvis. 



220 OPERATIVE OBSTETRICS 

The danger of uterine rupture must always be kept in mind in 
these manipulations. Should success not be immediately obtained 
under gentle manipulation, the operator should desist and perform 
embryotomy in the interests of the mother. The danger of uterine 
rupture may be estimated before operation by the tetanic condition 
of the uterine muscle, the presence of the contraction-ring, its dis- 
tance from the pubes, the distended condition of the lower uterine 
segment, and the size and consistence of the fetal head. Slight fever 
on the part of the mother, rapid pulse, restlessness and complaint, 
or severe abdominal pain contraindicate combined version and call 
for embryotomy. 

Internal Version. — This is usually termed podalic, as it is not 
often that the attempt is made to completely turn the fetus and bring 
the head to the pelvic brim by the introduction of the hand. As the 
name indicates, in this operation the hand is introduced within the 
uterus, and the fetus is dislodged sufficiently from its fault}^ position to 
permit the turning of the fetal body, so that its long axis is parallel 
to that of the birth-canal. In most cases iTrsion is followed by ex- 
traction, so that version and extraction are often considered as one 
operation, and spoken of, inaccurately, as version. 

The Indications for Version. — A transverse or oblique position 
of the fetus, the head not engaged and inaccessible for the forceps, 
prolapse of the cord while the head is presenting above the pelvic 
brim, a second child in twin pregnancy, conditions in which prompt 
delivery is necessary, but as the head has not descended and engaged, 
the forceps cannot be used, malpositions of the fetus which render 
the engagement and descent of the head impossible, are the princi- 
pal indications for the performance of version. In placenta pr^evia 
version is done to check hemorrhage at the sacrifice of the child's 
fife. On the contrary, in prolapse of the cord, version is performed 
to save the life of the infant. The advantages of version are 
that it enables the physician at once to diagnosticate accurately intra- 
uterine conditions which have caused labor to cease and it places 
the fetus practically under his control. With one accustomed to 



VERSION 



221 



operate by version, tlio operation eaii be performed with very little 
assistance and possibly without a trained ])(4'son. It is thus the 
expedient of the ginu^ral practitioner, should he b(^ ov(^rtaken while 
alone with some serious obstetric emergency. The performance of 
version requires, in itself, no instruments, although extraction is 




Fig. 132. — Bipolar version: Dislodging the head from the pelvic brim (Kerr). 



often accompanied by laceration, and the operator should be prepared 
to control hemorrhage and immediately repair lacerations. 

The Technic of Version. — For the successful performance of ver- 
sion the patient should be placed on a high table, at its edge, upon 
her back, the thighs thoroughly flexed upon the abdomen, the legs 
upon the thighs. If possible, the lower extremities should be sep- 



222 



OPERATIVE OBSTETRICS 



arated by assistants, as it may be necessary to vary the position of 
the limbs if extraction is to follow version. If the operator is alone 
and must anesthetize the patient and perform version without assist- 
ance, he may place the patient on her left side at the edge of a high 
bed and, standing opposite her, anesthetize her with chloroform with 
the left hand, and, introducing the right, perform ATrsion. The 




Fig. 133.— Bipolar version: Turning the child by combined manipulation (Kerr). 

suggestion has been made that in cases where the presentation of the 
fetus was complex and difficult to adjust, above the pelvic brim, that 
the patient be placed, if possible, upon her abdomen, thus straighten- 
ing the axis of the birth-canal and enabling the operator to draw 
the fetus downward easily. 

The anesthetic should, preferably, be chloroform during the per- 



VERSION 



223 



formance of version. If extraction is not to follow, anesthesia should 
cease as soon as version is complete. If the oi)erator intends to j)ro- 
ceed to delivery, ether should take the place of chloroform. The 
patient should be antiseptically i^repared, and a copious vaginal 
douche of lysol (1 per cent.) should be administered. In suspected 
cases a very thorough vaginal cleansing with tincture of green soap and 
lysol should be made, followed by copious irrigation with boiled water 




Fig. 134. — Bipolar version: Turning the child by combined manipulation: grasping 

the foot i^Kerr). 

and then bichlorid (1 : 4000) . The patient should be thoroughly 
catheterized when completely under the anesthetic. The operator's 
hands and forearms above the elbow should be made aseptic and 
covered with sterile rubber gloves or gauntlets. The limbs and ab- 
domen of the patient should be covered with sterile linen. The posi- 
tion of the fetus should be thoroughly mapped out by palpation and 
auscultation, and the operator should fix in his mind the probable 



224 OPERATIVE OBSTETRICS 

location of the lower extremities of the child. If, for example, the 
head is upon the left side of the mother, the back to the front, the 
right shoulder presenting, the lower extremities of the fetus will be 
found in the upper and right side of the mother's uterus. In com- 
plex presentations the operator should try to recognize the position 
of the back, and, naturally, search opposite this for the feet. That 



Fig. 135. — Podalic version: Grasping the feet (Farabeuf and Varnier). 

hand should be inserted into the uterus which, as the operator sits 
before his patient, is opposite the feet of the child. 

The hand should be folded into a cone and passed along the pos- 
terior wall of the vagina and pelvic floor as_far back as possible, thus 
avoiding the fetal body, which in transverse position lies usually to 
the front. Reaching the sacrum, the fingers should ascend upon the 



VIOKSION 



225 



side where the feet are sought, and the effort be made to grasp the 
lower foot of the child. If it is necessary to proceed promptly with 
extraction and both fcn^t are available, both should be taken. The 
foot or feet should be grasped between the fingers of the operator, the 
thumb being placed across them to the front to make the grasp 
secure. The operator should then bring the hand slowly and steadily 




Fig. 136. — Bipolar version: Bringing down the breech and legs by traction upon 

the foot (Kerr). 



dow^nward in the oblique diameter of the pelvis, remembering to 
turn the limbs of the child so that the heels point toward the pubes. 
The effort of the operator should be to bring the back of the child 
toward the pubes from the very beginning of version. The external 
hand may make pressure upon the abdomen, covered with sterile linen, 
gently pushing the head upward in the opposite direction from that 
in which the hand grasping the feet is traveling. Should manipula- 



15 



226 



OPERATIVE OBSTETRICS 



tion cause vigorous uterine contractions, the operator should hold 
the fetus in the position obtained and wait until the contraction is 




Fig. 137. — Version in breech presentation, first position; extended limbs; feet 
in the fundus of the uterus, bringing down the anterior and left foot with the left 
hand (Xagel). 



past. Remembering the danger of uterine rupture if the fetal body 
fails to move after gentle and patient efforts, the operator may be 
obliged to desist, and terminate labor in some other wa}^ When 



VERSION 



227 



one or both lower extremities i)rotrucle from the vulva, version may 
be said to have been aeeomplished. The operator may then deter- 
mine whether to allow the child to be expelled spontaneously or to 
proceed with extraction. If the extraction is not to follow version, 
a noose of gauze bandage ma}' be placed around the child's lower 




Fig. 138. — Version and extraction; grasping the foot (Kerr). 

extremities, and, if desired, a light weight may be attached to the 
bandage, thus making continuous but gentle traction. In placenta 
prsevia, where version is made to stop hemorrhage, such traction should 
not be employed. After version the operator should not proceed to 
extraction, but the parts should be thoroughly cleansed and the pa- 



228 



OPERATIVE OBSTETRICS 



tient given stimulants until the uterus acts spontaneously. If the 
child is not to be immediately dehvered, its body should be wrapped 
in warm sterile towels with the hope of saving its life. An exam- 
ination should be made to ascertain, if possible, that the cord is 
not pinched between the pelvis and the bod}^ of the child. If the 
cord is undergoing dangerous compression, it should, if possible, be 




Fig. 139. — Internal podalic version, the patient lying on her left side. The 
right hand of the operator is passed upward to grasp the left foot of the child. 
The fetus is in transverse position, shoulder presentation (Nagel) . 



carried to the side of the promontory of the sacrum, where pressure 
will be less. 

During version it is sometimes considered advantageous to retain 
a hold upon a prolapsed arm of the fetus. This may be done by 
passing a noose of gauze bandage around the prolapsed arm at the 
wrist, while the operator proceeds to turn the child. 



VERSION 



229 



Version After Pubiotomy and Section Through the Lower Uterine 
Segment. — Version and extraction after pubiotomy should be avoided. 
It is practically impossible to perform version and extraction without 
making pressure with the fetal head against the cut ends of the pubic 
bone; and such pressure must result in lacerations which would, in 
many cases, open into the pelvic or peritoneal tissues. After vaginal 




rr-fj^ 



rig. 140. — Internal podalic version. The operator has grasped the foot, and is 
bringing down the left and lower leg of the child (Nagel). 

Cesarean section or suprasymphyseal section through the lower 
uterine segment, version and extraction should be avoided if possible, 
because of the danger that turning may tear the lower uterine seg- 
ment and wound the peritoneum. 

The Results of Version. — In contracted pelves, before Cesarean 
section and pubiotomy were commonly employed, version was ad- 
vised and frequently practised. In many Continental clinics 10 



230 



OPERATIVE OBSTETRICS 



per cent, of cases of contracted pelves were delivered by version and 
extraction. This operation was followed by a considerable maternal 
mortality. In 22 cases Scheffzek^ lost 2 mothers; 3 mothers suffered 
from complications during recovery. His mortality rate for the 
children was 59.6 per cent. Hamies gives a fetal mortality of 34.5 







Fig. 141. — Internal version with the patient lying upon her right side, the 
operator introducing his left hand into the uterus, and with the thumb pushing 
the head of the child aside; while the fingers are carried upward to reach the feet. 
The left hand presses the breech down through the abdominal wall and uterus 
(Nagel). 

per cent.; Peham, of 60 per cent. Such results in the hands of expe- 
rienced operators have caused, in great measure, the abandonment 
of version in contracted pelves. Pollock - has sought to lessen the diffi- 



1 Archiv f. Gyn., Band 88, Heft 3, 1909. 

^ Trans, of the Obstetrical Society of London, vol. 4, 1906. 



VERSION 



231 



ciilty of version l)v i)lacin<2; tlu^ i)ati('nt in tlic Trendelenburg pos- 
ture. 

While version and extraction are followc^d by considerable 
moi-tality in contracted pelves, in normal pelves the maternal 
mortality is Init slightly greater than that of the use of forceps. 
The fetal mortalitv of version and extraction must ahvavs be con- 




I :u. 142. — Internal podalic version. The patient upon her right side; the left 
hand of the operator is passed over the breast of the child, pushing up the head 
and shoulders so that the breech may descend. The right hand of the operator 
assists bj' manipulating the uterus through the abdominal wall (Xagel) 

siderable, independent of the size of the pelvis. The manipu- 
lation necessary to turn the child favors the entrance of air into the 
uterus, and may be followed by air embolism, as in a case reported 
by Apfelstedt/ The patient, a multipara with normal pelvis, had 

1 Zentralblatt f. Gvn., Xo. 23, 1907. 



232 OPERATIVE OBSTETRICS 

face presentation and spontaneous labor ceased. After incisions 
into the cervix, hemorrhage and cohapse occurred. The placenta 
was found low in the uterus and version was immediately done. 
The patient steadily collapsed and died with symptoms of air embo- 
lism. 




Fig. 143. — Internal podalic version, as in the preceding. The breech has been 
brought sufficiently far down for the operator to grasp the upper right foot 
(Nagel) . 

Version may also cause the detachment, partial or complete, of 
the placenta, while the danger of uterine rupture can never be for- 
gotten. So far as the fetus is concerned, difficult version may cause 
fracture of the humerus in the endeavor to dislodge the arms from a 
vicious position, fracture of the thigh in endeavoring to bring down 
the lower extremities, partial dislocation of the joints of the lower 



VERSION 



233 



extremities, injury to the umbilical cord, injury to the child's face 
and head, and, where extraction follows with difhculty, fracture of 
the cranium with intracranial bleeding. The results of version clearly 
indicate that it is an operation in the interests of the mother, and 
that only in prolapse of the cord, with the conditions favorable for 
easy extraction, can it be considered an operation undertaken in the 









•_„j'-iiiiil1iii'i'^ 



Internal podalic version, as in the preceding, grasping the right ante- 
rior foot with the left hand of the operator (Nagel). 



interests of the child. The liability of septic infection during version 
is considerable, as the hand is introduced within the womb, and while, 
theoretically, it is within the membranes, there is abundant oppor- 
tunity for inf(^ction during the passage of the hand through the 
cervix. 

Spontaneous Version. — It has been observed in some cases that 
although the child was transverse at the pelvic brim, the shoulder 



234 



OPERATIVE OBSTETRICS 



impacted, and the fetus apparently immobile, after some time the 
child would be spontaneously expelled, the breech or head pre- 
senting. This is most apt to happen if the child be dead or macer- 






Fig. 145. — Bringing down the breech by combined manipulation, a shng being 
attached to one ankle, the operator making traction upon the sling with one hand, 
and pushing the head up with the other (Nagel). 

ated or if it be of unusualjy small size. This is much acceler- 
ated if the patient maintains a squatting posture. King^ draws 

^ Surgery, Gynecology, and Obstetrics, August, 1908. 



VERSION 



235 



attention to this tact, and advises tlio placing of such patients in a 
squatting postiU"e, the thigh o})i)osite the fetal head considerably 
advanced in front of the other; if the patient leans forward, steady- 
ing the body by grasping the side of the bed or a chair, the axis of the 




Fig. 146. — Podalic version complete, with the bringing down of the left foot (Nagel), 



pelvis is favorably directed, the abdominal muscles are stimulated 
to contraction, and spontaneous version may be hoped for. The 
writer can confirm King's observation, as he has several times seen 
spontaneous version follow this maneuver. 



236 OPERATIVE OBSTETRICS 

Dilation of the Cervix in Version. — In many cases it is necessary 
to perform version before the cervix is completely dilated. Unless 
the indications are most pressing, the operator should precede 
version by manual dilation. In the face of threatened hemorrhage 
he may introduce the hand as hastily as possible. The undilated 
condition of the cervix should warn the operator not to perform 
rapid extraction, especially in cases where the child is dead, exhausted 
from hemorrhage, or has been badly injured. If it is hoped to save 
the child, then the mother's cervix may be torn to permit the exit 
of the child, and immediately repaired after delivery. The use 
of dilating bags is rarely advantageous before vereion, as their action 
is too slow for dangerous cases, and the operator usualty prefers to 
perform dilation with the hand. ^Multiple incisions in the cervix 
preceding version may be used in cases where the cervical tissue is 
unusually dense and resisting. 

The Prognosis of Version and Extraction. — In dealing with 
patients and their friends, the operator should be careful to warn 
the friends of the mother that if extraction must be performed 
the chances of the child are not so good as those in normal labor 
or with the use of forceps. In cases where version is done without 
extraction, the necessity for sacrificing the child in the interests of 
the mother should be explained. Version is sometimes necessary in 
the case of fetal monstrosities, where an exact diagnosis of the fetal 
condition is impossible without the introduction of the hand. If an 
abdominal tumor be found comphcating the dehvery of the fetus, 
goiter, or some intracranial condition, the operator must prepare 
to perform embryotomy in addition to version and extraction. In 
deahng with monstrosities and macerated children the operator 
should take care not to leave the severed head within the uterus. 
It is better after ATrsion not to perform extraction in a case of dead 
and macerated fetus until a secure gi'asp of the skull has been ob- 
tained. If necessary, a decapitation hook may be introduced into 
the fetal mouth. 



EMBRYOTOMY 237 



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Brose: Zeitschrift f. Geburtshiilfe unci Gynakologie, Band 51, Heft 3, 

1904; Zentralblatt f. Gynakologie, Xo. 12, 1904. 
Burger: Monograph, Management of Labor in Contracted Pelvis, 

\\'ien, 1908; 
Chwiliwit'ky: Zentralblatt f. Gynakologie, X'o. 11, 1907. 
Groeschel: Zentralblatt f. Gynakologie, X'o. 46, 1907. 
Hannes: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 62, Heft 2, 

1908. 
Ingerslev: Journal of Obstetrics and Gynecology of the British Empire, 

January and February, 1909. 
King: Surgeiy, Gynecology, and Obstetrics, August, 1908. 
Kraus: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 56, Heft 

1 and 3, 1905. 
Krull: Archiv f. Gynakologie, Band 67, Heft 2. 1902. 
Ladner: Zentralblatt f. Gynakologie, Xo. 47, 1907. 
Leisewhz: Archiv f. Gynakologie, Band 86, Heft L 190S. 
Lichtenstein : Archiv f. Gynakologie, Band 81, Heft 3, 1907. 
Longus: Miinchener med. Wochens., Xo. 11, 1907. 
Miller: Miinchener med. Wochens., p. 323, 1907. 
Mm-er: Inaug.-Diss., Rostock, 1907. 
Xijiioff: Zentralblatt f. Gynakologie. Xo. 25. 1907. 
Peham: Monograph, Wien. Alfred Holder, 1908. 
Pfannenstiel: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 24, 

Heft 4, 1906 
Pollock: Transactions, Obstetrical Society of London, vol. 4, 1906. 
Rieck: Zentralblatt f. Gynakologie, Xo. 28, 1909. 
Schultze: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 30, Heft 

2, 1909. 
Schulz: Inaug.-Diss.. Breslau, 1905. 

Schwarzmeyer : Miinchener med. "Wochens., p. 801, 1907. 
Veil: Zentralblatt f. Gynakologie, Xo. 23, 1907. 

EMBRYOTOMY 

By embryotomy we understand the lessening of the fetus in size 
to permit its deliver}^ through the body of the mother. This is under- 
taken without regard to the life of the child, and so embryotomy is 
a child-destroying procedure. Probably the oldest of all obstetric 
operations, embryotomy has been largely superseded, in the case of 



238 OPERATIVE OBSTETRICS 

living children, by Cesarean section and pubiotoniy. The induction 
of labor endeavors to avoid embryotomy. 

The Indications for Embryotomy. — Embryotomy is indicated in 
cases where, by reason of pelvic deformity, excessive fetal size, or 
malformation, a dead or dying fetus cannot be delivered through the 
body of the mother without serious injury to her. If the fetus has 




Fig. 147. — Labor complicated by hydrocephalus (Bumm). 

been subjected to repeated attempts at delivery and to long-contin- 
ued and vigorous birth pressure, its life should not be considered in 
the same light with the life of a vigorous fetus before the beginning 
of labor. The presence of a monstrosity in the womb justifies embry- 
otomy. The presence of a syphilitic fetus in the womb would not 
justify embryotomy, for the newborn child may be treated for 



EMBRYOTOMY 



239 



syphilis with a fah- chance of succc^ss. In brief, when tlie fetus 
shares with the niothcn* some condition which rencku's its Hfe very 
doubtful, or wIumi it has been exposed to ineffectual efforts at 
delivery and long-continued birth pressure, and conditions are 
present which, in the interests of the mother, make delivery impera- 
tive, embryotomy may be i)erformed without hesitation. 




Fig. 148. — Impacted twins (Bumm), 

In the present enthusiasm for Cesarean section and pubiotomy, 
cases are sometimes subjected to Cesarean section which should be 
treated by embryotomy. As an example, a general practitioner was 
requested by a family to attempt forceps delivery in a primipara 
with contracted pelvis. He made the attempt in a private house 
and failed. The i)atient was then transferred to a hospital and, al- 



240 OPERATIVE OBSTETRICS 

though the patient had been some time in labor and the child sub- 
jected to biith pressure and to forceps pressure, Cesarean section 
was performed. The child died of biith pre:-sure shonly after 
deUvery and the mother died of septic peritonitis. It must be re- 
membered that ineffectual attempts at forceps delivery cannot be 
made without exposing the mother to graA'e danger of infection and 
the child to gTave danger of intracranial injury: hence, such cases 
are not proper for Cesarean section unless the operator is pre- 
pared, recogTiizing them as infected, to remove the body of the 
womb after delivering the child, or to ilrain the body of the womb 
by suprasymphyseal extraperitoneal secti<:>n. In the case described, 
embryotomy shouL;! have been done, the uterus packeil an<:l drained, 
with a reasonable chance of saving the mother's hfe. 

General Considerations Concerning Embryotomy. — As embry- 
otomy is a disastrous termination of labor, the operator should pay 
all deference to the feelings and beliefs of the patient and her family. 
If the parents and relatives cherish the belief that baptism is essen- 
tial for salvation, it may comfort them if the rite of baptism is ad- 
ministered to the fetus as soon as a ponion of its body protrudes 
from the mother. If the services of a prie>t cannot be conveniently 
obtained, a friend should be askel to perform this office. To spare 
the mother sorrow, care shouLI be taken not to expose the mutilated 
body of the cliild to the observation of friends and neighbors. If 
a monstrosity or a deformity exists, it shouLt be pointed out to the 
husband or some responsible relative, thus justifying the perform- 
ance of embryotomy. Instruments and appliances for embryotomy 
should not be exposed, and the operation should be done without 
the presence in the room of relatives other than the husband of 
the patient if he requests to be present at the operation. Care 
should be taken, if possible, to avoid exaggerated accounts of the 
operation from being given to the mother anil her friends. 

Craniotomy. — As the heail most frecpently presents, so that 
portion of the fetus most frequently lessened in size in embryot- 
omy has given the name most commonly apphed to the operation. 



E.MIUIYOTOMY 241 

Craniotomy consists in opening the fetal cranium. This simple 
operation was probably tlu^ first in obst(>tric surgery, and was per- 
formed in cases where spontaneous labor faiknl, the head could 
not be extracted with the hands, and was pulled out often piecemeal 
by the sharp hook. At present craniotomy may be performed by 




Fig. 149. — The perforator, having; been carried up the vagina under protection 
of the fingers of the operator's left hand, is being pushed into the skull in the neigh- 
borhood of the anterior fontanel (Kerr). 



simply perforating the cranium, and allowing the expulsive forces 
of labor to lessen the size of the cranium by forcing out its contents. 
This operation may be done by any piercing instrument which will 
penetrate the cranial bones. Sharp-pointed scissors are most fre- 
quently employed. Smelley's scissors have cutting edges to the outer 

16 



242 OPERATIVE OBSTETRICS 

aspects of the blades, and when the blades are separated cut through 
bony tissues. In performing craniotomy with scissors, a parietal 
bone is most often opened, as this is most available in the pelvic 
cavity. 




Fig. 150. — The blades are being separated by pressing together the handles (Kerr). 

Simply perforating the cranium is rarely satisfactory, because 
it lessens so Httle the size of the fetal head that the bony flaps close 
with intracranial pressure, and but little is effected by the operation. 
Accordingly, the effort ha? been made to make a i^ermanent opening 
in the cranium by the use of the trephine. The long trephine demised 



EMBRYOTOMY 



243 



by Martin is that usually cinplovLHl. In appl}-ing this instrument 
care must be taken that it is brought firmly against the cranial 
bone, and that it lIocs not slip when pressure is made. If the scalp 
is veiy edematous and thick, it shoukl be incised, allowing the 
operator to place the trephine firmly against the bone. An assist- 
ant should steady the head by suprapubic pressure while the trephine 




Fig. 151. Fig. 152. 

Figs. 151 and 152. — Auvard's three-bladed cranioclast and its use Biunm\ 



is perforating, .llthough the parietal bone is the site of choice for 
trephining, .still, in necessity, any portion of the fetal head available 
may be utiHzed. The trephine shoukl remove a complete button of 
bone, leaving a permanent opening which will not close on pressure. 
Cranioclasis. — After trephining, the size of the head remains prac- 
tically the same. To secure its diminution an instrument should be 



244 OPERATIVE OBSTETRICS 

passed through the trephine opening, and the membranes and brain 
thoroughly torn. The cranium should then be washed out with an 
antiseptic fluid injected by a piston syringe; if such is not available, 
a copious irrigation of the cranial cavity with a fountain syringe 
should be employed. The operator then passes through the tre- 
phine opening the cranioclast, of which Braun's is the type usually 
employed. This instrument contains two blades, one serrated for 




Fig. 153. — The head extracted by the cranioclast (Bumm). 

a firmer grasp and the other fitting smoothly over it. It has a pelvic 
curve and a fixation screw. The serrated blade is passed within the 
cranium, the other externally, and the two are firmly clamped as 
near the base of the cranium as possible. If the cranioclast is applied 
to a parietal bone only, and strong traction is made, the bone will 
be torn free from its attachment, leaving the balance of the head. 
When the cranioclast has been securely applied, traction should be 



EMBRYOTOMY 



245 



nia^le downwanl and backward in the axis of the birth-canal and the 
heatl cautiously delivereil over the pehic floor. The contents of 
the cranium are frequently forced out through the trephine opening 
during the extraction of the head. The head emerges with the era- 




Fig. 154. — Perforation and application of the three-bladed cephalotribe through 
the mouth in a case of face presentation Kerr.) 

niocla^n at the apex, more or less drawn out, in proiwrtion to the 
diflBcuhy of the extraction. 

Cephalotripsy.— In delivery by the cranioclast the size of the 
head is le^ened by the pressure of the pelvic wall-. If the head 
be unduly ossified, such pressure nmy be ineflfectual in reducing the 
head sufficiently to permit its safe extraction. The base of the 



246 OPERATIVE OBSTETRICS 

cranium may be so resisting as to form a serious obstacle to delivery. 
In these cases it is necessary to crush the head. This is accom- 
lished by the cephalotribe, a pair of strong forceps with a compression 
screw at the outer extremities of the handles. This instrument is 
appUed along the sides of the pelvis, compression made, the instru- 




Fig. 155. — Showing ideal grasp of head with the three-bladed cephalotribe: 
one blade well down over face and the other over occiput (Kerr). 

ment relaxed, and then again apphed until the head is thoroughly 
crushed. It can then be deUvered in the grasp of the cephalotribe. 
The dangers of cephalotripsy he in the fact that the broken cranial 
bones may protrude through the scalp and wound the mother dur- 
ing delivery. 



EMBRYOTOMY 



247 



Basiotripsy. — Taniior and others have (U^viscnl instruments com- 
bining the perforator and the cephalotril)(\ These instruments con- 




Fig. 156. — Showing the effect of crushing only one-half of the head in cases of 
posterior parietal presentation (Kerr). 

sist of a central stem having at its extremity a firm screw like an 
augur, which can be carried through the cranium and fastened into 



248 OPERATIVE OBSTETRICS 

the bones at the base of the skull. On each side of this are the 
blades of the cephalotribe, which can be applied, crushing the head. 
The head thus crushed and perforated is delivered in the grasp of the 
instrument. 




Fig. 157. — Showing the perforation through the posterior fontanel in case of 
extreme flexion of the head. It will be observed that the blade placed over the 
face does not reach further than the forehead (Kerr). 

Unusual Forms of Craniotomy. — It may be necessary to per- 
form craniotomy on the after-coming head, when the cranium may 
be entered through the foramen magnum or, in rarer cases, through 
the mouth of the child. In impacted face presentation it may be 
necessary to open the head through the face in any manner least 



EMHKVOTOMV 



249 



apt to wound the inotluT. In brow pmsontation the face is the 
available area for eraniotoniy. In these cases especial care must 
be taken to avoid th(^ slii)pino; of the instruments employed, and to 
introduce them sufficiently deeply into the cranium to obtain a firm 
hold. 




Fig. 158. — Showing the cranioclast shpping because the anterior blade is not 
applied far enough down over the face (Kerr). 

Cleidotomy. — By cleidotomy is understood the severing of one or 
both clavicles to lessen the size of the fetal shoulders, thus reducing 
the bisacromial diameter. The operation may be performed upon the 
living or dead fetus, and is indicated for excessive development of 
the shoulders, preventing their birth after the expulsion of the 
head. Blunt-]:)ointed scissors upon a long handle are recjuired, and 
under the usual precautions the fingers are inserted and the clavicle 
located. The scissors are then passed along the internal fingers, and 



250 



OPERATIVE OBSTETRICS 



with a sawing motion the clavicle is cut through. Usually the most 
available portion of the bone is severed, but if a choice can be made, 
it should be as near the trunk of the body as possible. As the result 
of this the bisacromial diameter is considerably lessened and deUvery 
often rendered possible. 




Fig. 159. 



-Perforating the after-coming head through the posterolateral fontanel 

(Kerr). 



The clavicle may be broken in difficult breech extraction in 
bringing down the arms, thus permitting the birth of the child. In 
some cases the operator may deliberately risk this accident with the 
hope of securing a living fetus. 



EMBRYOTOMY 



251 



Evisceration. — It may be necessary to open the thorax or al^do- 
men of the cliikl for accumulation of fluid, soHd tumors, or diseased 
conditions of the viscera. Such oi)eration might be termed eviscera- 




"X 



I 



\\ 



\ 




Fig. 160. — "Wound in the fetus produced by cleidotomy 



tion. For this purpose blunt-pointed scissors should be used, the 
operator having carefully mapped out the position of the cliild and 
being sure that he does not mistake maternal for fetal tissue. The 
fetus in utero has had ovarian cyst preventing labor, accumulations 



252 



OPERATIVE OBSTETRICS 



in the abdomen greatly altering its size, and accumulations of fluid 
in the chest as well. 

In hydrocephalus, the breech presenting and the head retained 
within the uterus, it may be necessary to open the spinal canal with 



r 
\ 




Fig. 161. — Showing the collapsed shoulder-girdle after cleidotomy. The child was 
a very large one and had to be extracted with the cephalotribe (Kerr). 

the hope of securing drainage and permitting the delivery of the 
head. The effort has been made to save the hfe of the fetus in these 
cases by removing a portion of the intracranial fluid. This effort 



EMHUYOTOMY 



253 



has rarely been successful, and should not be made with confidence. 
A trocar and canula have usually been employed in the spinal canal, 
in the lower dorsal or upper lumbar region. 

Decapitation and Amputation. — In impacted shoulder presenta- 
tion with threatened uterine rupture, amputation of the prolapsed 
upper extremity may become necessary. This decomposes the wedge 
formed by the fetal shoulder and enables the operator to do version 
or to reach the neck of the child more safely for decapitation. Blunt- 
pointed scissors is the safest instrument for this operation, and 








Fig. 162. Fig. 163. 

Figs, 162 and 163. — Braim's blunt hook and its use in decapitation (Bumm). 

strong traction should be made downward upon the prolapsed arm 
by an assistant during the amputation. The operator should 
remove as much from the shoulder as he can without risk of w^ound- 
ing the mother. 

To perform decapitation, Braun's decapitation hook has proved 
practical, simple, and as safe as any instrument of the sort. More 
elaborate instruments, carrying cutting blades, are not easily steril- 
ized, often fail to work, and may wound the mother. The introduc- 
tion of the hook may be aided by traction upon the prolapsed arm 



254 OPERATIVE OBSTETRICS 

made by an assistant. Guided by the fingers of one hand, the hook 
is passed over the neck and brought firmly into its tissues, then, in a 
rotary motion from side to side, the hook is brought slowly but firmly 
down until the spinal column is felt to separate, it is then brought out 
through the skin, or the skin may be incised with blunt-pointed scissors. 
The severed head is then pushed upward into the uterus and the body 
of the child delivered as is most convenient. This can sometimes be 
effected by traction upon the prolapsed arm, if it has not been necessary 
to do amputation. If delivery is very difficult, it will be necessary 
to deliver the child by the feet and breech. The severed head may 
be brought by pressure to the brim of the pelvis, and usually delivered 
by forceps. If this is not possible, it should be extracted by crani- 
otomy. 

In the lack of suitable instruments, decapitation has been per- 
formed by passing a stout cord, dipped in vinegar, around the fetal 
neck, and gradually sawing through the spinal column. 

The Delivery of the Fetus Piecemeal. — In desperate cases it may 
be necessary to remove the fetus little by little. In these cases 
labor has long been neglected, the birth-canal is so swollen that the 
operator can reach the fetus with great difficulty, and a typical opera- 
tion is impossible. By the use of blunt-pointed scissors and long 
forceps with serrated blades a fetus can be removed in this manner. 
The operation is difficult and often dangerous and would never be 
done from choice. 

The Frequency and Results of Embryotomy. — Embryotomy is most 
often performed in contracted pelves, and as Cesarean section and pubi- 
otomy have become perfected, embryotomy is much less frequent. 
Scheffzek, in 1011 cases of contracted pelves, performed perforation 
43 times (4.2 per cent.) . Most of these cases were craniotomy. Peham 
estimates the frequency of embryotomy as 6.32 per cent.; Hannes, 
5.1 per cent.; Baisch, 2.9 per cent.^ In Scheffzek's cases the child 
was living at the time of operation. In general, from the reports 
of various cHnics, it may be stated that at the present time perfora- 

1 Archiv f. Gyn., Band 88, Heft 3, 1909. 



EMBRYOTOMY 255 

tion is performed on the living child in not more than 2 per cent, of 
cases of contracted pelves. This may well illustrate the advance of 
obstetric surgery from the early days, when all cases in which sj)on- 
taneous labor faileil were terminatal by perforation and extraction. 
The maternal mortality of embryotomy is estimated at its lowest at 
between 1 and 2 per cent., and at its liighest at from 4 to 7 per cent. 
Like the use of the obstetric forceps, in skilful hands the operation 
has little maternal mortaUty in selected cases; but so many cases of 
embryotomy have been neglected durmg labor and come under ob- 
servation when infected, that the mortality in these cases must remain 
high, although it may not be directly ascribable to the operation. 

In 1.300 cases of labor in the service of the Lying-in Hospital 
of Xew York, Gushee reports 122 craniotomies.^ Ln 77 cases the 
fetus was dead before the operation: there were 11 cases of hydro- 
cephalus, making a total of 88 operations performed from neces- 
sity. In 12 cases a premature chilil was firmly hell in an undilated 
cer\ix. Of these patients 56 were sent to the hospital by physicians 
and mid wives, and among these there were 11 deaths: 6 from shock 
and hemorrhage, 3 from eclampsia, and 2 from septic infection. 
Among the cases treated in the out-patient department, 2 died from 
sepsis. In the 122 cases, 53 had contracted pelves, 29 were threatened 
with uterine rupture from distention of the lower segment, and among 
these were 12 cases of premature labor. 

In the Dresden Clinic, Meissner- reports 57 craniotomies upon 
the li\ing and 112 upon the dead fetus in 29,725 labors, during a 
pericKl of fourteen and a half years. The relative frec[uency was, in 
21,023 cases of labor, 49 embryotomies upon the living child and 
8 upon the dead. In the operation done upon the K^ing child the 
pelvis was contracted in 49 cases, normal in 8. These patients 
presented various comphcations — eclampsia, nephritis, septic infec- 
tion, hematoma, and exhaustion. In some the fetus was a monstros- 
ity, and in 3 the pelvis was highly deformed, with the mother in 

' Bulletin of Lj-ing-In Hospital of Xew York. June. 1907. 
- ArcWv f. Gati.. Band SI. Heft 3, 1907. 



256 OPERATIVE OBSTETRICS 

such a condition as to prevent section. In 8 some operation had been 
attempted outside the hospital; 3 mothers had serious disease, mak- 
ing section impossible, and 10 patients were considered infected in 
previous attempts at deUvery. The maternal morbidity was 44 
per cent. Two mothers died, 1 from eclampsia, and 1 from rupture 
of the uterus. 

In the 122 cases where the child was already dead, the pelvis was 
contracted in 95.5 per cent. Among these mothers 7 died, 3 from 
eclampsia, 1 from caries of the vertebrae, 1 under anesthesia, 1 from 
nephritis, and 1 with streptococcus infection. The maternal mor- 
tality in cases where the child was dead or dying was 1.2 per cent. 

Bibliography 
Bretschneider : Arcliiv f. Gynakologie, Band 63, Hefts 1 and 2, 1901. 
Burger: Monograph, Management of Labor in Contracted Pelvis, 

Wien, 1908. 
D'Erchia: Annah di Ostetricia, Nos. 7 and 8, 1902. 
Doderlein: Miinchener m. Wochenschrift, No. 32, 1909. 
Gushee: Bulletin of Lying-in Hospital, New York, June, 1907. 
Hammerschlag : Zentralblatt f. Gynakologie, No. 31, 1907. 
Hannes: Zeitschrift f. Geburtshiiife und Gynakologie, Band 62, Heft 

2, 1908. 
Hegar: Beitrage z. f. Geburtshiiife und Gynakologie, Band 11, 1907. 
Hofmeier: Zeitschrift f. Geburtshiiife und Gynakologie, Band 59, 1907, 

and Band 48, Heft 2, 1903. 
Jolly: Zentralblatt f. Gynakologie, No. 51, 1908. 
Katz: Monatsschrift f. Geburtshiiife und Gynakologie, Band 21, Heft 

4, 1905. 
Kiistner: Zentralblatt f. Gynakologie, No. 42, 1909. 
Latzka: Monatsschrift f. Geburtshiiife und Gynakologie, Band 14, 

Heft 6, 1901. 
Leisewitz : Archiv f . Gynakologie, Band 86, Heft 1, 1908. 
Lierenberger : Zentralblatt f. Gynakologie, No. 48, 1902. 
Meissner: Archiv f. Gynakologie, Band 81, Heft 3, 1907. 
Menge: Miinchener med. Wochens., Band 54, p. 1465, 1907. 
Peham: Monograph, Wien, Alfred Holder, 1908. 
Pendl: Zentralblatt f. Gynakologie, No. 40, 1905. 
Perniche: Zentralblatt f. Gynakologie, No. 35, 1900. 
Pf annenstiel : Verhandl. d. deutschen Ges. f. Gyn., 12, Kongress, p. 

351, 1907. 



POSTLHAi. e\lahgi:me\t 257 

Ratlbruch: Geburtshiilfe, Jena, Fischer, 1907. 

Schulte: Inaug.-Diss., Giessen, 1905. 

Seeligmanii: Zentralblatt f. Gynakologie, Xo. 3, 1905; Miinehcner med. 

Wochens., Band 54, p. 695, 1907. 
Veit: Berliner klin. Wochens., p. 149, 1907. 
Voorhees: American Journal of Obstetrics, December, 1902. 
Zechel: Inaiig.-Diss., Gottingen. 1906. 
Zweifel: Zentralblatt f. Gynakologie. Xo. 12. 1905. 



Vaginal Extraction Preceded by Enlargement of the 

BiRTH-CANAL 



POSTURAL ENLARGEMENT 

The increased mobility of the pelvic joints during pregnancy is 
accompanied by mobility in various poitions of the pelvis. The 
symphysis pubis may become so mobile that the patient experiences 
great inconvenience in walking, with considerable pain. Pain in 
the sacro-iliac joints during pregnancy must be ascribed to mobility in 
this region. The sacrococcygeal joint may become painful also from 
increased motion. The younger the patient the gi'eater the mobility 
of the pelvis. The older the patient the less wiU the pelvis enlarge 
by this means. 

The pelvis may be enlarged during labor through the pressure 
of the fetus and also from weight applied through various postures 
which the patient may assume. When unassisted, women frequently 
kneel at the side of a bed. resting the head and shoulders upon the edge 
of the bed : othei's lean forward, grasping a chair, the instinctive desire 
seems to be to bend the trunk of the body forward and flex the lower 
extremities upon the trunk, in many cases rotating the thighs out- 
ward, ^lercurio and Walcher have shown that the two halves of 
the pelvis may be caused to rotate outward at the sacro-iliac joints 
by utilizing the weight of the lower extremities. This may be accom- 
plished by placing the patient, with her sacrum raised, upon the 
edge of a firm and padded table, sufficiently high to permit the lower 
extremities to swing freelv above the floor. The extremities are then 



258 



opeeati\t: obstetrics 



rotated outwaKl, when it will be found that the anteroposterior 
diameter of the pelvis has been appreciably increased, and that there 




Fig. 164. — The TTalcher position Kerr's. 

has also been some gain in the obUque diameters. The pelvic floor 
is not relaxed by this procetliire. and hence, at the moment of deliv- 



POST r HAL EXLAKGEMEXT 259 

ery, the thighs s^houkl be flexed upon the abdomen of the mother to 
secure the relaxation of muscular tissue. The muscles at the brim 
of the pelvis are also not relaxed by Walcher's position, unless the 
table be so arranged that the trunk of the mother's body is raised 
somewhat from the shouklers down. Whik^ the gain by this posture 
is not great, it is often sufficient to permit the passage through the 
pelvic brim of the fetal head. This posture is also favorable for 
traction downward and backward by the forceps, and this fact may 
account for some of the benefits which accompany its use. 

To utilize this posture the patient must be placed sufficiently high 
from the floor. The mistake is often made of allowing the patient's 
feet to rest partly upon the floor, which greatly lessens the efficiency 
of the maneuver. Unless the edge of the table be carefully padded 
the patient may sufTer considerable pain upon recovery from the 
operation because of pressure upon the sacrum. Two strong assist- 
ants are required to hold the patient in position, for otherwise the 
weight of the lower extremities is sufficient to drag the patient from 
the table. These assistants should also be prepared to flex the 
thighs and legs when the child is passing over the pelvic floor. With 
the patient in Walcher's position, the tendency' is for the operator to 
bring the fetal head strongly against the pubes and the tissues just 
behind it; unless especial care be taken, serious bruising and injury to 
the base of the bladder may result. In all defiveries in this position 
the operator must often assume the very inconvenient posture of sit- 
ting or kneeling upon a low chair or upon the floor, as nearly directly 
under the patient as possible. In this way traction may be directed 
backward and wounding of the bladder avoided. 

Lateral and Knee -chest Postures. — In the left lateral posture, with 
the hips at the edge of a l3ed or table, the patient is favorably placed 
for the pas.sage of the child through the pelvic brim and for its exit 
over the pelvic floor. As there is no pressure upon the perineum the 
pelvic floor is free to dilate, and better dilation is secured than 
when the patient lies upon the back. In the knee-chest posture, with 
the fetus impacted in the pelvic brim, the tendency will be for the fetus 



260 



OPERATIVE OBSTETRICS 



to gravitate upward, and thus to assume, in the absence of uterine 
contractions, a more favorable position. Version may sometimes 
be performed with the patient in the knee-chest posture, using the 
force of gravity to dislodge the child. 

The Squatting and Sitting Postures. — Among primitive people 
parturition was often accomplished in the squatting posture, the 
patient grasping a tree or the hands of a friend. In this way the 
two halves of the pelvis were rotated outward, the fetus brought 
into the axis of the birth-canal, and its descent aided by the force of 
gravity. Among Oriental races gravity was utilized by placing the 




Fig. 165. — Knee-chest posture for parturient woman CBumm). 

patient in a sitting posture upon chairs or stools especially con- 
structed to permit the exit of the child. 

The Influence of Exercise Upon the Passage of the Child Into the 
Pelvis. — The value of exercise in the latter months of pregnancy in 
increasing the mobility of the pelvis and bringing the child to engage 
cannot be questioned. Especially is this true in shghtly contracted 
pelves, where the engagement of the head is often greatly facilitated 
by work done by the patient with the trunk of the body bending 
forward. The writer has repeatedly seen in hospital patients the 
scrubbing of a floor or flight of stairs, done regularly in the last weeks 



SYMPHYSEOTOMV, I'UBIOTOMY. HEBOSTEOTOMY 2G1 

of gestation, followcHl by descent and the engagement of the fdiis in 
moderately contracted pelves. This part of thc^ household work in 
the hospital is, for this reason, usually assigned to such patients. 
The value of walking in increasing pelvic mobility and causing engage- 
ment has been recognized. 

To secure pelvic mobility during pregnancy, the patient should 
avoid constricting clothing and exercise moderately but frequently. 

Bibliography 

Cramer: Monatsschrift f. Geburtshiilfe und Gynakologie. p. 525, 1900. 

Gauss: Zentralblatt f. Gynakologie, Xo. 28, 1907. 

Kaks: Zeitschrift f. Geburtshiilfe und Gynakologie. Band 54, Heft 2, 

1905. 
Kerr: Journal of Obstetrics and Gynecology of the British Empire, 

April, 1903. 
Proceedings International Congress, Amsterdam, 1899. 

SECTION OF THE PELVIS: SYMPHYSEOTOMY, PUBIOTOMY, 
HEBOSTEOTOMY 

When pelvic mobihty, increased by posture, does not permit the 
engagement and descent of the fetal head, recourse may be had to 
opening the bony girdle of the pelvis. This may be accompKshed 
by opening the pubic joint or by severing the pubes through the 
bony tissue. 

Symphyseotomy 

At present, time and space need not be utilized in a detailed dis- 
cussion upon symphyseotomy. Its successful performance in pre- 
antiseptic times, its abandonment, and revival are familiar to all 
obstetricians. At present there is a tendency to decry tliis opera- 
tion for the more recent procedure of pubiotomy. 

Symphyseotomy consists in opening the pubic joint. This may 
be done subcutaneously or by direct incision, by what is termed the 
open method. Usually the cartilage of the joint only is severed. In 
some cases, through unusual ossification or through inaccuracy on the 
part of the operator, a portion of the bone is cut asunder. The 
results of symphyseotomy are the downward and outward rotation 



262 OPERATIVE OBSTETRICS 

of the two halves of the peMs. caused by the weight of the lower 
extremities. The mechanism is the same as that of pehic enlarge- 
ment ^ith Mercurio's or TTalcher's position, increased by the severing 
of the peMc girdle. If the subpubic ligament be not severed ui s^^n- 
physeotomy, the rotation of the halves of the pehis is less. The 
diameters of the peMc brim are enlarged after s^Tuphyseotomy in 
varji'mg degree. In aU cases the enlargement is appreciable and of 
practical importance. The halves of the pubes separate during this 
operation stifficiently to permit the operator to place from two to 
four fingers between the severe:! 1x)nes. If the thighs be rotated out- 
ward the separation is uicreased, but if pressiu-e be made upon the 
sides of the pehis and the thighs rotated inward, the separation is 
less. The enlargement of the pehis after s^Taphyseotomy is mi- 
mediate. so that the head descends immediately into the pehis, imless 
disproportion has been verA' markel. 

Indications for Symphyseotomy. — S^Tuphyseotomy, if chosen ui 
preference to pubiotomy, is iudicated ia cases where the disproportion 
between the head and the pehis is not great, and where the cervix, 
pehic floor, and vagina have been dilated by previous labor or are 
readily dilatable. The reason for the first hmitation lies iu the fact 
that sufficient is not gained in the pehis by symphyseotomy to over- 
come gi'eat disproportion. The effort to dehver the head through 
the pehis after s^Tnphyseotomy. in highly contracted pelves, results 
in the death of the fetus and fatal laceration for the mother. It is 
important that the birth-canal should have previously been dilated 
or be dilatable, for, if such is not the case, diu-ing the dehvery of the 
head after symphyseotomy the anterior vaginal waU will be brought 
against the severed ends of the ptibes, and serious and sometimes 
fatal laceration, with hemorrhage, wiU ensue. As symphyseotomy 
is a child-saving operation, it shotdd not be perfonned where the 
fetus is dead or hkely to die, and it should not be tmdertaken in in- 
fected women, for it opens a region rich in blood-vessels to the access 
of septic material. Its range is. therefore. Hmited, but in tliis narrow 
compass it has utihty. 



SYMPHYSEOTOMY. ITinOTOMY. H I:H( )STr.OT()M Y 2(33 

Methods of Performing Symphyseotomy. — A met hoi I largely 
emi^loycd, giving good results, and among the earliest consists in 
placing the patient upon her back. The genital canal and the region 
about the pubes having been prejxared l)v thorough antisepsis, a 
longitudinal incision in the median line just above the border of 
the iHibes is then made, extending through the skin and fascia, and 
permitting the operator to separate the recti muscles. The fingers 
are then passed behind the pubes, pushing the peritoneal sac, which 
is unopened, upward, and passing the fingers beneath the pubes. 
The bladder, having been emptied by catheter, a sound or stiff catheter 
is placed within the bladder and given to an assistant, who depresses 
the uretlu'a slightly and hokls it to one side. A l3lunt-pointed l^is- 
toury or symphyseotomy knife is then passed along the fingers behind 
and beneath the pubes. AVith a gentle sawing motion the knife is 
brought upward and sUghtly backward until the cartilage is di^dded 
and the joint is felt to yield. Two assistants, one on each side, then 
make pressure upon the trochanters to prevent the peMs from sepa- 
rating too widely. If the symphyseotomy must be complete, the 
subpubic ligament is then severed with a iDlunt-pointed bistoury and 
the pehds immediately gapes asunder. From one to two fingers, 
and sometimes four, can be laid between the ends of the pubes. 

While the assistants support the sides of the pelvis by pressure 
upon the trochanters, the patient is drawn down to the edge of the 
table and the cliild delivered, usually by forceps. In many cases the 
occiput rotates posteriorly and is so delivered with but little difficulty. 
During deUvery pressure is maintained o^'er the sides of the pelvis 
to prevent overstraining of the sacro-iHac joints. After delivery the 
uterus is completely emptied, and usually packed with 10 per cent. 
iodoform gauze. The bladder shoukl again be catheterized and a 
thorough examination made of the urethra and the anterior vaginal 
wall for lacerations; if such exist, they should be immediately closed 
with chromicized catgut, and if the urethra or bladder has been 
wounded, a catheter, to which a long rubber tube is attached, should 
be placed in the bladder for drainage. If severely lacerated, the cer- 



264 OPERATIVE OBSTETRICS 

vix should be repaired . and the pehdc floor and perineum. A vaginal 
packing of Ijichlorid gauze should be insened. 

The patient is drawn back upon the table. an<;l the symphyse- 
otomy wound, wliich was at fii'st tamponed with gauze, is examined 
after the removal of the tampon. If there be no bleeding, it is usually 
best to leaA'e a small strand of gauze passing thi'ough the abdominal 
incision to the bottom of the space beliind the pubes. The incision. 
is then closed and covered by antiseptic gauze. The lower stitch is 
left untied, so that it may be brought together after the gauze drain in 
the wound has been remoA'ed. This occurs thirty-six hours after the 
operation, when the stitch is tie-l. 

The pelvis is immobilized Ijy passing entirely about the peMs 
a broad strip of the best Cjuality rubber adhesive plaster, so applied 
that the center of the strip is over each trochanter. During its 
application the two hahTS of the pehis should be brought tightly 
together and so held by assistants. Over this may be placed a 
many-taileil abdominal binder. 

After tliis operation the patient should He upon her back for a 
week or ten days, after AAdiich the stitches are remoAxd from the 
SA'mphyseotomy wound and a new adhesive stri]} or a canvas belt 
with buckles is applied. The patient may then tiu'ii in bed as she 
desu'es, and usually sits up at the end of the tliird week. Her going 
about will depenil upon the in(;liAddtial case and the firmness of the 
pehic joints. 

The Subcutaneous Method of Symphyseotomy. — This consists 
in severing the pubic canilage as one would a tendon in subcuta- 
neous tenotomy. A blimt-pointed. narrow-bladed. strong knife is in- 
serted tlirough the smallest possible incision, cutting the symphysis 
from aboA'e >;lownward: it is then withdraAMi and delivery efTected in 
the usual manner. 

Open Symphyseotomy. — By the open method, the operator sits 
in front of the patient, her thighs and legs being flexed and rotated 
outward, and. pushing to one side the urethra an-;! the tissues about the 
chtoris, cius directly down upon the pubic joint. The canilage and 



SYMrHYSEOTOMY, rUBIOTOMY. HEBOSTKOTOMY 205 

ligament are sevorcMl iin(l(>r diiTct vision and the delivery ])(M'fornie(l 
as before. After delivery the wound is closed \\ith continuous 
catgut. 

The Immobilization of the Pelvis. — In addition to the method 
(lescribed, the jielvis may be innnoliilized after symphyseotomy by 
lateral pressure with sand-bags, or l)y placing the patient upon a 
canvas cot, which sags sufficiently with hcu* weight to cause the 
sides of the cot to make pressure against the trochanters. Each 
of these methods has given satisfactory results. 

The Results of Symphyseotomy. — In the majority of cases a 
practically substantial union of the pubes occurs. In some, where 
unusual ossification has been present in the cartilage, bony union 
may develop. In others the joint is mobile for some time after 
operation. If one or both of the sacro-iliac joints have been severely 
strained, the patient will have pain in this region indefinitely, and 
will sometimes complain that she cannot for this reason walk. "With 
other patients walking is difficult because of the movements of the 
two halves of the pubes. Some patients develop an hysteric fear 
of locomotion, and it is very difficult to get them to make an effort to 
walk, although perfectly able to do so. It is only in exceptional 
cases that necrosis or caries occurs in the joint or that the joint 
becomes infected. 

The ImmobiUzation of the Pelvis at the Time of Operation. — 
Efforts have been made to hold the severed halves of the pelvis 
in apposition by drilling or wiring the pubes together. Others 
have passed stitches of strong chromicized catgiit between the peri- 
osteum of the severed halves. The proposition has been made to 
insert sterile ivory between the halves of the pubes to secure per- 
manent enlargement of the i)elvis. None of these methods is neces- 
sary in the majority of cases. 

The Accidents and Complications of Symphyseotomy. — Lacera- 
tions of the anterior vaginal wall, opening the pelvic and sometimes 
the peritoneal cavities, rupture or wounding of the urethra, rupture 
of the veins about the vulva followed bv hematoma of the labia, free 



266 oPERAxm: obstetrics 

lieinorrhage followed or accompanied by infection^ injury to the base 
of the bladder from which the patient recovers very slowly, and septic 
infection, have all followed this operation. The puerperal period 
may be compUcated by infection, anemia following hemorrhage, 
prostration the result of slow imion and long confinement in a 
recumbent posture. 

The Permanent Results of Symphyseotomy. — If the pehds is slightly 
enlarged in its anteroposterior and oblique diameters, the enlarge- 
ment var}Tng from J to 1 cm., and extensive laceration and infec- 
tion do not occur, the patient has a practically soimd pubic bone 
and is able to work as well as before. If tln-ombosis of the vessels 
of the thigh develops, her convalescence may be indefinitely 
retarded. 

The Results of Symphyseotomy for the Child. — As the opera- 
tion is imdertaken largely in the interests of the child, the fetus 
should escape essential injur}\ The posterior rotation of the occiput 
so commonly observed has, in my experience, caused no complica- 
tions, as the head wiU be readily delivered by forceps. If the opera- 
tion has been late, the fetus may be subjected to severe birth pressiu*e. 
perishing as a consequence. 

Mortality and Morbidity. — The maternal mortality of symphyseot- 
omy has been estimated at from 8 to 12 per cent. This did not do 
the operation justice, for it was imdertaken where craniotomy 
shoidd have been done and where the patient had become exhausted 
and infected before help was suromoned. With a primar}' operation 
done in a hospital by competent operators, the mortality of s^Tuphyse- 
otomy in properly selected cases does not exceed 2 per cent. The 
maternal morbidity cannot be accurately reckoned, as it depends so 
greatly upon the judgment and skill of the individual operator. 
Here the selection of the operation primarily, before the patients' 
birth-canal has been bruised or infected by imsuccessful attempts 
at delivery, greatly lessens the morbidity. 

Fetal Mortahty and Morbidity. — The fetal mortality and mor- 
bidity after svTnphyseotomy should not be greater than that after 



SYMPHYSEOTOAIY, PUBIOTOMV. HEROSTEOTOMV 267 

the use of forcoi)s. In inarkiMl (lis|)r()])ortion, however, fetal mor- 
tality ami morlmlity may be from 7") to 90 per cent. 

Symphyseotomy Without Extraction. — In cases seen in the early 
stage of labor, where marked disproportion is absent, the effort has 
been made to secure spontaneous extraction by opening the pelvis 
and awaiting the spontaneous expulsion of the child. The sym- 
physeotomy wound is covered with sterile gauze and every precaution 
taken to avoid infection. In some of these cases spontaneous labor 
has resulted, with very satisfactory results. In many, however, it 
was necessary to complete delivery by operation. 

The proximity of the urethra to the incision, the danger of wound- 
ing the neck of the bladder, extensive gaping of the two halves of the 
pelvis, the formation of hematoma in the lal^ia, the ready access of 
infection to the wound, and the danger of wounding the veins in 
the central hne of the pubes have led operators to choose some 
other method than symphyseotomy for opening the peMs. Pubiot- 
omy, brought into prominence first by Gigli, is advanced as an im- 
provement upon symphyseotomy. 

PUBIOTOMY 

The Indications for Pubiotomy. — The indications for pubiotomy 
are those for symphyseotomy : moderate disproportion between the 
head and pelvis and a birth-canal which has been dilated or is dilat- 
able; to these should be added a sound and uninfected condition of the 
mother and a vigorous state of the child, for we do not believe, with 
some, that pubiotomy is an operation for infected cases, nor is it an 
operation of last resort when other means of extraction fail. As a 
primar}' operation justice is done this procedure, but not when 
otherwise chosen. 

The Technic of Pubiotomy. — In performing pubiotomy, that 
side of the pelvis is usually selected toward which the occiput of the 
child is directed, and, therefore, the peMs is usually opened upon 
the left side. A point is chosen on the outer side of the tubercle 
which marks the outer aspect of the pubic joint on each half of 



268 



OPERATIVE OBSTETRICS 



the pubic bone. An opening having been made above, over the bone, 
the fingers are passed behind the pubes and the unopened peritoneal 
sac pushed upward and backward out of the way. A carrier needle 
armed with a ligature is then passed around the pubes from below 
upward ; by this means a fine saw is made to encircle the bone. The 
bone is then severed with the saw from below upw^ard. If bleeding 
is absent, the pubiotomy wound is closed and delivery effected. 




Fig. 166. — The symphysis pubis from the front. The lines A and B represent 
the directions in which the pubes may be divided in the operation of pubiotomy: 
A is the direction recommended by Van der Velde; B, that recommended by Gigli 
(Kerr). 



If bleeding develops, the pubiotomy wound is tamponed, delivery 
effected, and the bleeding subsequently stopped. Doderlein's needle 
is very commonly employed for passing the saw around the pubes. 
In the subcutaneous method the opening is not enlarged sufl^- 
ciently to admit the fingers, but through the smallest possible aperture 
the needle is passed around the bone and the saw introduced. In 
the open method a free incision is made upon the bone and the bone 
severed under the guidance of vision. As bony tissue is to be trav- 



SYMPHYSEOTOMY, PUBIOTOMY, HEBOSTEOTOMY 2G9 

ersal only, a saw will be efficient, hence the use of the blunt-ix)int('<l 
knife employed in symphyseotomy will not avail. 

Pubiotomy may be double in rare cases or cases of extreme pelvic 
contraction. In repeated pubiotomy it is desirable to make the 
second incision upon the side opposite to the first. 

Delivery After Pubiotomy. — The pelvis gapes asunder so soon as 
the pubes is severed, usually more promptly than after symphyseot- 
omy, as there is no subpubic ligament to hold the bones together. 
The head enters the pelvis readily in proper cases, and may then 
be delivered by forceps. The two halves of the pubes after section 
are seldom in apposition, and do not remain so without artificial 
support. 

The Advantages of Pubiotomy. — In contrast to difficult forceps 
extraction and prophylactic version in contracted pelves, pubiotomy 
enlarges the pelvis and permits the egress of the child. It also saves 
the life of the child, and in this way is in direct competition ^ith cra- 
niotomy. It avoids the dangers of alxlominal section, leaves the 
tissues with scarcely an appreciable scar, is not so formidable to 
the patient and her friends, and leaves the mother, in favorable 
cases, in good permanent condition. 

The Disadvantages of Pubiotomy. — The disadvantages of pubiot- 
omy are: the liability to severe laceration with hemorrhage, often 
accompanied by infection, injuries to the base of the bladder, throm- 
bosis of the veins of the ower pelvis and thighs, permanent mobility 
of the pelvis where bony union rarely occurs, and more or less per- 
manent disabihty following the operation. 

In order that the operation shoidd have its just place and its merits 
be accurately known, it must be an operation of election, a primary 
operation, performed in hospitals. It is unfitted for septic cases, 
and as an operation of last resort should give place to craniotomy 
or abdominal section, followed by hysterectomy. Under these limi- 
tations, pubiotomy has a distinct field. 

The Results of Pubiotomy for the Child. — ^In properly selected 
and well-conducted cases pubiotomy is a child-saving operation. 



270 



OPERATIVE OBSTETRICS 



Where disproportion is marked, forcible delivery by forceps after 
pubiotomy would subject the fetus to dangerous birth pressure 
and may be accompanied by fractures of the cranial bones. Its 
direct infant mortality is nearly that of forceps. In improperly 




Fig. 167. — Pubiotomy by Doderlein's method (Costa, Annali di Ostetricia, No. 6, 

1910). 

selected cases its fetal mortality is that of prophylactic version 
in highly contracted pelves, from 75 to 100 per cent. 

The Technic of Pubiotomy. — The operator must beware of com- 
phcations caused by the saws employed in pubiotomy. These in- 



^ 





Fig. 168. — Pubiotomy by Doderlein's method (Costa, Annali di Ostetricia, No. 6, 

1910). 

struments not infrequently break, and hence the operator must 
be provided with several before commencing the operation. A 
broken piece of the saw may become fixed in the pubic bone and 



SYMPHYSEOTO-MV, riBIOTOMY, IIKBOSTEOTOMY 



271 



its removal occasion difficulty. During the operation severe hem- 
orrhage may develoj) from a source not readily found. In these 
cases a vein or venous })lexus has been opened, and })ressure only 




Fig. 169. — Pubiotomy performed b3' Bumm's method (Costa, Annali di Ostetricia, 

No. 6, 1910). 

can control it. Severe laceration of the pelvic tissues is more apt 
to follow pubiotomy than symphyseotomy, because the cut ends 
of the bone are sharper and more readily wound the tissues. In 




Fig. 170. — Pubioi^omy performed by Bumm's method (Costa, Annali di Ostetricia, 

Xo. 6, 1910). 

delivery after pubiotomy lateral pressure must be made on the 
trochanters, as after symphyseotomy. The immobilization of the 
pelvis after the operation is accomplished by the same methods 
described for symphyseotomy, but efforts to wire together the severed 



272 OPERATIVE OBSTETRICS 

bones have not been universally adopted. The examination of the 
pelvis by skiagrams shows fibrous union in the majority of cases. 

The Place of Pubiotomy as an Operation. — The abundant litera- 
ture of the subject reports a varied experience in this operation. 
Tweedy^ had sudden and profuse hemorrhage during the operation 
until the bone was severed. The bleeding ceased suddenly and was 
easily controlled by pressure. The child was successfully delivered 
by podalic version. On examination it was found that the bleeding 
had occurred from severe lacerations in the cervix, which w^as torn 
into the lateral fornix. The pelvic wound had become a compound 
fracture, and this w^as drained with iodoform gauze. Lacerations 






Fig. 171. — Pubiotomy performed by Bumm's method (Costa, Annali di Ostetricia, 

No. 6, 1910). 

were repaired and the patient resuscitated from extreme collapse. 
The patient recovered, with a widening of J inch between the 
bones. Reiff erscheid ^ gives the maternal mortality as 5.94 per cent. 
Semmerlink^ had extensive injury to the bladder during pubiot- 
omy, from which the patient recovered by constant drainage. 
Baumm'^ had 10 successful cases; in 5 there were severe lacerations; 
in 3 partial necrosis of the ends of the bone occurred ; in 7 the puer- 
peral period was complicated; in none did a firm callus form after 

1 Journal of Obstetrics and Gynecology of the British Empire, May, 1907. 

2 Zentralblatt f. Gyn., No. 48, 1906. ^ jj^j^j 

* Monatsschrift f . Geburtshtilfe und Gynakologie, Band 25, Heft 4, 1907. 



SYMPHYSKOTOMY, TUBIOTOMY, HEBOSTEOTOMY 



273 



operation. Hocheisen^ followed Baumm's method, which consists in 
the subcutaneous use of Bauimu's iioedle. The insertion of the 



•D— . 




—-a 



Fig. 172. — a, Left pubic tubercle; &, absence of right pubic tubercle (Costa, Annali 
di Ostetricia, No. 6, 1910). 






/ • 



I 




Fig. 173. — a and h, Line of section (Costa, Annali di Ostetricia, No. 6, 1910). 

needle makes the wound not larger than .5 cm., readily closed by 
catgut immediately after the operation. The nearer to the symphysis 

1 Archiv f. Gyn., Band 80, Heft 1, 1906. 
18 



274 



OPEEATIVE OBSTETRICS 



the needle was passed, the less was the bleeding. After delivery the 
genital tract was firmly tamponed with gauze, a T-bandage placed 
OA'er the Aiilva. and a firm binder around the pelvis. Spontaneous 




Fig. 174. — Operation by open method (Costa. Annali di Ostetricia. Xo. 6. 1910). 

labor was awaited, and if this did not occur, the forceps was applied. 
In 1 of these patients vesicovaginal fistula followed, which closed 





Fig. 175. — Resulting scar (Costa, Annali di Ostetricia. Xo. 6. 1910). 

spontaneously. In 1 an .Y-ray picture of the pelvis showed that 
symphyseotomy instead of pubiotomy had been performed. In 
another a verA- extensive tear occurred near the urethra and the 



SYMPHYSEOTOMY, PUBIOTOMY, HEBOSTEOTOMY 275 

patient's puerperal i)eri()(l was complicated by thrombosis. In 5 per 
cent, the puerperal period was normal, while in 50 per cent, some 
complications arose. One child died shortly after the operation. 

Zweifel ^ performed 52 symphyseotomies by the open method and 
12 subcutaneous symphyseotomies; 2 pubiotomies by the open 
method and 1 subcutaneous pubiotomy. In the symphyseotomies 
done by the open method 3 women and 4 children died. The 2 pu- 
biotomies done by the open method had fever, but finally recovered. 
The subcutaneous pubiotomy did better. Among the subcutaneous 
symphyseotomies no mother died. Doderlein^ collected the records of 
294 cases of pubiotomy; by the open method the maternal mortality 
was 10.4 per cent., by the subcutaneous, 4.1 per cent. The highest 
mortality occurred in patients infected at the time of operation. 
Among these the mortality was 12.5 per cent. ; among 149 not infected 
at the time of operation but 1 died. In infected cases Doderlein would 
perform embryotomy and not pubiotomy. The dangers of hemor- 
rhage and wounds of the surrounding tissues are emphasized. In 55 
cases done by the open method there was 1 severe laceration of the 
bladder, followed by death from sepsis. In 170 subcutaneous pubiot- 
omies, injuries to the urinary tract occurred in 25. By his own 
method of operating Doderlein avoided such accidents, and calls 
attention to the importance of guarding the bladder and urethra by 
the finger applied along the posterior wall of the pubes. The opera- 
tion, although subcutaneous, is thus done under control of the finger 
and injury can be avoided. Lacerations opening into the vagina 
must often occur in primiparse delivered after pubiotomy by forceps. 
In the 55 cases by the open method, 8 such injuries occurred, 2 of 
which were severe. All of these patients were delivered by forceps, 
6 were primipara^ and 2 multiparse. In the 170 subcutaneous opera- 
tions, injuries communicating with the vagina occurred in 20 — 12 
primiparse and 8 multiparae; 15 of these patients were delivered by 
forceps, 4 by version and extraction. Among 19 spontaneous labors 

^ Verhandl. d. deutschen Gesell. f. Gyn., Band 12, p. 33; Zentralblatt f. Gyn., 
p. 163, 1907; Annali d. Gyn. et d'Obs., p. 531, Sept., 1907. - Ibid. 



276 OPERATIVE OBSTETRICS 

following pubiotomy there occurred no severe injury. In primipar- 
ous patients with poorly developed birth-canal, incisions into the 
vagina and pelvic floor should be made before delivery. The forma- 
tion of hematoma is not attended with great danger unless it is 
accompanied by wounding of the urinary tract, through which 
infection gains access to the hematoma. 

So far as the children were concerned, in 55 cases done by the 
open method 3 deaths occurred among the children. In 170 cases 
by the subcutaneous method there were 12 fetal deaths. These 
resulted from cerebral lacerations and intracranial bleeding. All 
of these children were dehvered by forceps extraction; there was 1 
case of prolapse of the cord. Spontaneous labor after pubiotomy is 
most favorable for the child. In choosing the operation Doderlein 
would not perform it in a pelvis whose true conjugate was less than 
6.75 cm. 

As regards the permanent enlargement of the pelvis following 
pubiotomy, in 8 patients subsequent labors seemed not to be made 
easier nor the pelvis larger by pubiotomy. In 5 of the 8 patients 
pubiotomy was done the second time; the children were larger than 
in the first labor, as is naturally the case. If spontaneous labor 
is to occur after pubiotomy, it must happen from some other cause 
than the enlargement of the pelvis. The severed bones rarely heal 
firmly, but usually by fibrous tissue. 

In the same discussion, Baumm reports 43 cases, with the recov- 
ery of all the mothers and the loss of 2 children. Frantz had oper- 
ated upon 11 cases, losing 1 mother from double thrombosis in the 
spermatic veins. In 1 case the patient was unable to walk two 
months after operation, and in a third case inguinal hernia developed 
through the separated ends of the bones. Fehling operated on 19 
cases; Kustner, on 5; Rosthorn, on 8; von Herff, on 5; Baumm, on 14; 
Walcher, on 15, with 3 cases of laceration of the bladder; Fromme, 
on 13, with the death of no mother and 1 child, and in 15 cases, with 
1 mother and 1 child lost. The majority of these operators pre- 
ferred the subcutaneous method. Efforts to increase the size of the 



SYMrHYSEOTOMV, Tl BIOTOMY, HEBOSTEOTOMY 277 

pelvis after pubiotoiny have been made by Hammerschlag and Polano. 
These efforts have not been successfuL In a case observed by 
Tandler one and a half years after pubiotomy so large a callus was 
present that the size of the pelvis was lessened and not increased. 
When a second pubiotomy was made there occurred a connective- 
tissue union, through which the bladder wall and peritoneum i)ro- 
lapsed. Although it would seem that the bladder would be more often 
injured after symphyseotomy than after pubiotomy, Zweifel, in 65 
cases of symphyseotomy, saw no injury to the bladder or urethra. 

There is no Cjuestion about the added frec[uency of thrombosis 
after pubiotomy. Kannegieser^ reports 30 cases of subcutaneous 
pubiotomy in the Dresden Clinic, and, reviewing the literature of the 
subject, finds the maternal mortality variously estimated at from 2J 
to 10 per cent. The fetal mortality he states at 19 per cent, for opera- 
tions for enlargement of the pelvis, and 40 per cent, for induced labor. 
In his own cases he had a maternal mortality of nil, but morbidity 
averaging do per cent. The fetal mortality in his cases averaged 
8 per cent. In 23 cases he studied carefully the after-effects of the 
operation, the .r-ray showing the complete formation of bone in 7 
cases. There was enlargement of the diagonal conjugate varying 
considerably in amount, and in many patients there was unusual 
mobility in the pelvic joints. He collected 15 cases, in which spon- 
taneous birth, with full-term children, occurred after pubiotomy. 
Lichtenstein- has studied the results of version and extraction before 
and after pubiotomy. In 110 cases, where the child was turned before 
the pubes was opened, fetal mortality was 32.81 per cent.; in 44 cases, 
in which the child was not turned until after the pelvis was opened, 
fetal mortality was 13.64 per cent. The average fetal mortality in 
pubiotomy, when the child was delivered by version and extraction, 
was 22.62 per cent. In 39 pubiotomies, in his chnic in Berhn, ^lartin^ 
saw injuries to the bladder and urethra in 3 cases. Sigwart^ had 5 

1 Archiv f. G^m, Band 81, Heft 3, 1907. - Ibid. 

^ Monatsschrift f. Geburtshijlfe und Gynakologie, Band 25, Heft 5, 1907. 

* Zentralblatt f . Gyn., No. 20, 1907. 



278 OPERATIVE OBSTETRICS 

pubiotomies in private houses; the mothers recovered, but the puer- 
peral period was complicated, and one of the children died. Deliv- 
ery was effected by forceps or version. Truzzi/ after pubiotomy, in- 
serted between the halves of the pubes a piece of calf's rib, 14 mm. 
wide and 3 cm. long, decalcified in 19 per cent, alcohol and then soaked 
in salt solution. No stitches were used and the bone was held in posi- 
tion by pressure. Good union occurred with considerable enlargement 
of the pelvis. Seitz ^ examined with the cystoscope, twenty days after 
operation, a patient who had a wound in the bladder after pubiotomy. 
The wound had healed, but a diverticulum in the bladder had formed. 
Mann^ observed necrosis of the pelvic bone after pubiotomy, the 
patient being unable to walk for some time. The dead bone was dis- 
charged through a fistula, which finally closed. The patient became 
pregnant and had a spontaneous abortion at three months. Hernia de- 
veloped in the scar of the operation. Kromer,* after pubiotomy and ex- 
traction with forceps, found in his patient a wound in the tissues near 
the urethra. This was closed by suture, but the patient's recovery 
was prolonged and complicated. She walked with pain on leaving 
the hospital fifty-seven days after operation. At the next pregnancy 
pubiotomy was again performed, with the hope that spontaneous 
labor would follow. It did not, however, and the patient was dehv- 
ered by vaginal Cesarean section, with version and extraction. 
Mother and child recovered. In a fatal case, Hammerschlag^ found 
that the pubiotomy wound had made an opening 3 cm. long into the 
bladder. Offergeld ^ experimented in an endeavor to increase the for- 
mation of bony tissue between the halves of the pubes. His conclu- 
sions are that firm bony tissue cannot be expected in these cases, 
that the action of the saw during the operation, and the fluids which 
collect through hemorrhage and congestion, prevent the development 
of bony tissue. He also endeavored to ascertain the best method for 
preventing infection in wounds after pubiotomy. Where such com- 

1 Zentralblatt f. Gyn., No. 20, 1907. 2 j^id., No. 20, 1907. 

3 Ibid., No. 44, 1907. * Ibid., No. 44, 1907. ^ Ibid., No. 33, 1907. 

^ Monatsschrift f . Geburtshulfe und Gynakologie, Band 26, Hefts 1 and 2, 1907. 



SYMPHYSEOTOMY, PUBIOTOMY, HEBOSTEOTOMY 279 

municated with the vagina a fatal result usually followed. He en- 
deavored to counteract infection in the medulla of the pelvic bone 
by producing venous hyperemia through i)ressure applied by band- 
ages. The patient's temperature did not fall, but her general condi- 
tion became better. Scheffzek^ reports 9 symphyseotomies and 18 
pubiotomies in 1301 cases of contracted pelves. There were severe 
lacerations of the vagina in 7 cases, 2 of which terminated fatally. 
In 3 of these patients the wounds made the fracture compound, 
but 29.6 per cent, of the mothers had normal puerperal periods. The 
others all had complications of greater or less severity. The fetal 
mortality was 33 J per cent, in both symphyseotomy and pubiotomy; 
in pubiotomy alone, 27.7 per cent. 

Williams- reported 13 operations for pubiotomy, 9 by himself 
and 4 by his assistants, with no maternal and 3 fetal deaths. The 
pelves were 6 generally contracted rachitic, 2 flat rachitic, 2 justo- 
minor, and 3 funnel shaped. 

In the first 10 the true conjugate measured from 7 to 8.5 cm. 
(2.8 to 3.4 inches); the funnel-shaped pelves had transverse diam- 
eters at the outlet of 7 cm. (2.8 inches). In 11 cases the operation 
w^as not performed until the patient had been in the second stage of 
labor from two to ten hours. The presenting part had failed to ad- 
vance. Manual dilation of the vulva and vagina was performed 
before beginning the operation, and Doderlein's method was fol- 
lowed, except in 1 case, w^here Gigh's open method w^as chosen. 
The child was immediately delivered by forceps in 10 cases, by breech 
extraction in 3. There was but slight hemorrhage in 12, and in 1 
case profuse bleeding and shock from a deep vaginal tear communi- 
cating with the pelvic cavity. Of the 13 patients, 9 w^ere primiparse; 
in 3 patients suture of perineal tears was required; in none was the 
bladder injured, and in none w^as the urine blood stained. When 
the placenta had been delivered, vaginal and perineal wounds were 
repaired and healed satisfactorily. The upper pubiotomy incision 

1 Archiv f. Gyn., Band 88, Heft 3, 1909. 

^ American Journal of Obstetrics, August, 1908. 



280 OPERATIVE OBSTETRICS 

was first closed with interrupted catgut and then a small drain of 
iodoform gauze was passed through the labial opening and a broad 
band of adhesive plaster about the hips. In bed a Bradford frame 
was used to immobiUze the pelvis. The patient was allowed to 
move as soon as she felt inclined, and usually turned upon her side 
in a few days after the operation. 

Although these operations proceeded favorably, the puerperal 
period was undisturbed in only 6 cases. In 7 the temperature 
ranged from 105.2° to 102.5° F. In 2 cases there was consider- 
able distention, but no serious infection developed. 

The earliest getting out of bed was on the fourth day, when one 
patient did so without leave, but without serious injury. With one 
exception, the patients got up between the sixteenth and twenty- 
third days; on the average, the twentieth; leaving the hospital on the 
thirtieth day. Most of them walked without difficulty, a few of 
them having a slight limp for a short time. Of the 13 patients, 10 
were seen afterward, reporting themselves in good health. 

So far as the immediate results of the operation were concerned, 
in more than half the cases caries formed on the anterior pubic surface. 
Posteriorly the bone was smooth, and in some a notch could be 
felt upon the upper and lower margins, showing the ends of the in- 
cision. There was no bony union. In 4 cases the cut ends of the 
bone moved when the patient walked. The sacro-ihac joints were 
injured in 1 case, but this disappeared after a month. The pelvis 
remained unchanged after operation, except in 1 funnel-shaped 
pelvis, where the distance between the ischia increased 1 cm. (.39 
inch). All the patients showed edema of the vulva, pronounced in 
3 on the side of operation; 2 patients had hematocele with indura- 
tion; 1, phlebitis in the leg; 1, stitch infection, and in 3 it was neces- 
sary to use the catheter for some time. 

One child was lost after breech extraction from asphyxia; one 
child died of birth pressure. 

Pregnancy had occurred after the operation in 3 of the patients, 
and 1 had spontaneous birth, the biparietal diameter of the fetal 



SYMrHYSEOTUMY, PUBIOTOMY, HEBOSTEOTOMY 281 

cranium measuring S.5 cm. (3.4 inches). In these mothers' pelves 
the true conjugate was 7 cm. (2.8 inches). Another patient has 
since been pregnant twice, having spontaneous premature labor at 
the seventh month. 

In the majority of these cases Doclerlein's was the method em- 
ployed, consisting in introducing the finger through a small incision 
along the upper border of the pubic arch, in the region of the pubic 
spine. The soft parts were then separated from the posterior surface 
of the pubic bone. The bladder was thus protected and the small 
incision was not prejudicial. A curved needle was then passed through 
the labium majus beneath the bone. This method was satisfactory. 

It was thought of giTat importance in these cases that the vaginal 
outlet should be thoroughly dilated by the gloved hand before 
beginning the operation. 

Cesarean section early in labor, under favorable circumstances, 
has a maternal mortality of 1.2 per cent., with no mortality for the 
child. The maternal mortality of pubiotomy should be less than 2 
per cent, in primary operations. This is much less than that of 
s^^mphyseotomy. 

Wihiams beheves that the induction of labor in moderate degrees 
of pelvic contraction will be superseded by pubiotomy. In these 
cases but 5 or 6 per cent, require operation, while if the induction of 
lalx)r be done, pregnancy w^ould be interrupted unnecessarily in from 
25 to 30 per cent. The fetal mortality in induced labor is much higher 
than after pubiotomy. Pubiotomy competes with high forceps, pro- 
phylactic version, and craniotomy rather than with Cesarean section. 
It should be strictly kept as a primary operation for uninfected cases, 
and not selected after the failure of high forceps for version. Under 
these circumstances craniotomy should be selected. To be success- 
ful the operation should be limited to hospitals and to experienced 
operators. 

The Pelvis After Pubiotomy. — To determine the permanent con- 
dition of the pelvis after this operation, Christofoletti^ examined the 

1 Zentralblatt fur Gynakologie, Xo. 14, 1908. 



282 OPERATIVE OBSTETRICS 

pelvis in 2 patients dying some time after the operation. There 
was considerable bony callus on the interior surface of the pelvis, 
the levator ani muscle had been injured in delivery, and the distance 
between the symphysis and the ileopectineal tubercle was increased 
on the side of operation. In another case there was no bony union, 
and very slight enlargement on the operative side. The slight 
increase in pelvic size gained by the operation was considerably less- 
ened by the development of callus on the internal pelvic surface. 

Burger ^ found the pelvis permanently enlarged in 25 patients 
operated upon in Schauta's clinic. The true conjugate was increased 
in some 1 cm. Union was fibrous, rarely bony. 

To Procure a Permanent Enlargement of the Pelvis. — Among other 
methods Schickeie ^ incised the bone about one-third of its thickness, 
prolonging the incision laterally, bringing the saw out on the oppo- 
site surface. This incision is planned to avoid bony union, and, by 
making the cut of considerable length, secures fibrous union, provid- 
ing for considerable pelvic enlargement. 

In Bumm's experience^ 52 cases with the subcutaneous method 
had given satisfactory results. One patient only died from embolic 
pneumonia. 

Jardine* operated upon a case of moderate pelvic contraction 
whose recovery was complicated by severe lacerations, vesico- vaginal 
fistula, and necrosis of the bone. The patient was discharged three 
months after admission with fibrous union of the pelvis, and able 
to walk comfortably. His unfavorable opinion of the operation is 
shared by Peham. 

In estimating the final results of the operation, it is abundantly 
proved that bony union cannot be expected. Oberndorfer^ examined 
the pelvis fourteen months after operation. His radiograms and illus- 
trations of microscopic sections failed to show the sUghtest evidence 



1 Zentralblatt f. Gynakologie, No. 14, 1908. 

2 Ibid., No. 17, 1908. ^ Ibid., No. 19, 1908. 

^ Journal of Obstetrics and Gynecology of the British Empire, March, 1908. 
^Zentralblatt f. Gynakologie, No. 7, 1908. 



SYMrHYSEOTOMY, PUBIOTOMY, HEBOSTEOTOMY 283 

of bony union. The histologic elonicnts necessary for the produc- 
tion of bone were entirely wanting. 

Disturbance of locomotion following pubiotoniy has been rei^orted 
by various writers. The French believe that in comparison with 
symphyseotomy, pubiotoniy is followed by fewer complications. 

Jeannin and Cathala^ published in tabulated form 39 cases by 
French operators, showing favorable results for the mothers. The 
puerperal period, however, had a high morbidity rate. 

The most extensive recent paper giving the results of pubiotomy 
is that of Schliifli.- In all, he has collected and examined the results 
of 700 cases. The general mortality rate for the mothers was 4.82 
per cent.; for the children, 9.18 per cent. In 510 cases, hemorrhage 
immediately following operation required attention. This varied in 
degree, from hemorrhage proving rapidly fatal, to that of moderate 
quantity. In 15.49 per cent, of cases lacerations occurred opening 
into the vagina. The usual tear of the pelvic floor occurred in about 
18 per cent. In general, laceration of the birth-canal proved fatal 
in 40.6 per cent, of cases. The bladder was wounded in 12.35 per 
cent., the puerperal period complicated b}" fever in 31.76 per cent., 
and by thrombophlebitis in 8.23 per cent. There was hernia between 
the cut ends of the bone in 7.5 per cent., prolapse of the vagina in 
24.17 per cent., and incontinence of urine in 4.17 per cent. 

Comparing these statistics with those of symphyseotomy and other 
methods of delivery, it is evident that pubiotomy is not a simple 
operation, and one to be chosen only under the most favorable cir- 
cumstances. 

Bibliography of Symphyseotomy, Pubiotomy, Hebosteotomy 

Allen: American Journal of Obstetrics, August, 1906. 

Baumm: Monatsschrift f. Gebui'tshiilfe und Gynakologie, Band 25, 

Heft 4, 1907. 
Bauer: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 63, Heft 1, 

1908. 

1 L'Obstetrique, October, 1908. 

2 Zeitschrift f. Geburtshulfe und Gynakologie, Band 64, Heft 1, 1909. 



284 OPERATIVE OBSTETRICS 

Bertino: La Ginec. Revista practica., vol. 4, p. 73, 1907. 

Brun: Annali di Ostetricia, No. 6, 1907. 

Bumm: Zentralblatt f. Gynakologie, No. 32, 1906, and No. 19, 1908. 

Burger: Gyn. Rundsch., p. 489, 1907; Verh. der deutsch. Ges. f. Gyn., 
Band 12, p. 287, 1907. 

Christofoletti: Zentralblatt f. Gynakologie, No. 14, 1908. 

Crede: Zentralblatt f. Gynakologie, No. 23, 1906. 

Doderlein: Verh. der deutsch. Ges. f. Gyn., Band 12, p. 93, 1907, full 
discussion; Surgery, Gynecology and Obstetrics, February, 1908. 

Ehrlich: Zentralblatt f. Gynakologie, No. 20, 1908. 

Fehling: Zentralblatt f. Gynakologie, Nos. 44 and 48, 1906. 

Ferroni: Annali di Ostetricia, No. 2, 1908. 

Frank: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 15, Heft 
5, 1902, and Band 25, Heft 3, 1907; Zentralblatt f. Gynakologie, 
No. 20, 1907. 

Fry: American Journal of Obstetrics, March, June, July, August, 1907; 
Surgery, Gynecology, and Obstetrics, vol. 5, No. 2, August, 1907. 

Futh: Verh. der deutsch. Ges. f. Gyn., Band 12, p. 273, 1907. 

Gauss: Zentralblatt f.. Gynakologie, p. 857, 1907. 

Gibson: Journal of Obstetrics and Gynecology of the British Empire, 
May, 1907. 

Gibson, Tweedy: Journal of Obstetrics and Gynecology of the British 
Empire, May, 1907. 

Gigli: Zentralblatt f. Gynakologie, No. 41, 1905. 

Guiccardi: Zentralblatt f. Gynakologie, No. 28, 1908. 

Hammerschlag : Zentralblatt f. Gynakologie, No. 33, 1907. 

Hartmann: Zentralblatt f. Gynakologie, No. 21, 1907. 

Henkel: Zentralblatt f. Gynakologie, No. 8, 1906; Zeitschrift f. Ge- 
burtshiilfe und Gynakologie, Band 57, Heft 1, 1906; Verh. der 
deutsch. Ges. f. Gyn., Band 12, p. 244, 1907; Miinchener med. 
Wochens., p. 1368, 1907. 

Herman: Transactions, Obstetrical Society of London, vol. 42, Part 4, 
1900. 

Hocheisen: Archiv f. Geburtshiilfe und Gynakologie, Band 80, Heft 1, 
1906. 

Jardine: Journal of Obstetrics and Gynecology of the British Empire, 
March, 1908. 

Jeannin and Cathala: L'Obstetrique, October, 1908. 

Jessen: Zentralblatt f. Gynakologie, No. 8, 1906. 

Jewett : American Journal of Obstetrics, December, 1906. 

Jewett, Mann, Reynolds, Fry : American Journal of Obstetrics, Septem- 
ber, 1901. 



SYMPHYSEOTOMY, PUBIOTOMY, HEBOSTEOTOMY 285 

Kannegeiser: Archiv f. ({ynakologie, Band 81, Heft 3, 1907. 

Kelirer: Monatssclirift f. Geburtshiilfe unci Gynakologie, Band 2, Heft 

2, and Band 2, Heft 3, 1905. 

Kromer: Verb, der deutseh. Ges. f. Gyn., Band 12, p. 281, 1907; 
Zentralblatt f. Gynakologie, No. 41, p. 1231, 1907; Hegar's Beitr. 
z. Geb. u. Gyn., p. 255, 1907. 

Leopold: Zentralblatt f. Gynakologie, p. 1319, 1907. 

Lerda: Zentralblatt f. Gynakologie, No. 1, 1908. 

Lichtenstein : Archiv f. Gynakologie, Band 81, Heft 3, 1907. 

Maire: Presse. med.. No. 69, 1907. 

Mann: Zentralblatt f. Gynakologie, No. 44, 1907. 

Martin: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 25, Heft 
5, 1907. 

Mayer: Verb, der deutseh. Ges. f. Gyn., Band 12, p. 332, 1907; Mo- 
natsschrift f. Geburtshiilfe und Gynakologie, Band 25, 1907. 

Menge: Verb, der deutseh. Ges. f. Gyn., Band 12, p. 313, 1907. 

Miiller: Korrespondenzblatt f. Schweizer Arzte, p. 612, 1907. 

Nacke: Zentralblatt f. Gynakologie, p. 1633, 1907. 

Neu : Monatsschrift f . Geburtshiilfe und Gynakologie, Band 27, Heft 4, 
1908. 

Oberndorfer: Zentralblatt f. Gynakologie, No. 7, 1908. 

Offergeld: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 26, 
Hefts 1, 2, and 6, 1907. 

Peham: Verb, der deutseh. Ges. f. Gyn., Band 12, p. 328, 1907; Zen- 
tralblatt f. Gynakologie, No. 23, 1908. 

Pinard: Therapeutique a. la Clinique Baudeloque, 1889-1907. 

Pisarzewski: Gaz. Lekarska, No. 36, 1907. 

Preller : Monatsschrift f . Geburtshiilfe und Gynakologie, Band 25, Hefts 
4 and 5, 1907; Zentralblatt f. Gynakologie, No. 20, p. 44, 1907. 

Prentiss: American Journal of Obstetrics, May, 1909. 

Rainer: Zentralblatt f. Gynakologie, No. 45, 1907. 

Raineri: Zentralblatt f. Gynakologie, p. 1401, 1907; La Rassegna. 
d'Ostetricia e. Ginec, No. 16, 1907; Annali di Ostetricia e. 
Gineeologia, vol. 2, No. 29, 1907. 

Reifferscheid : Zentralblatt f. Gynakologie, No. 48, 1906; Yerh. der 
deutseh. Ges. f. Gyn., Band 12, p. 316, 1907. 

Rissmann: Zeitsehrift f. Geburtshiilfe und Gynakologie, Band 57, Heft 

3, 1906. 

Riihle: Archiv f. Gynakologie, Band 82, 1907; Monatsschrift f. Geburts- 

hulfe und Gynakologie, Band 24, Heft 3, 1906. 
Ruppert: Hegar's Beitrag. z. Geburtshiilfe und Gynakologie, Band 11, 

1907. 



286 OPERATIVE OBSTETRICS 

Sachs and Lehmann: Zeitschrift f. Geburtshiilfe und Gynakologie, 
Band 63, Heft 1, 1908. 

Sandstein : Journal of Obstetrics and Gynecology of the British Empire, 
March, 1902; British Medical Journal, January 25, 1902. 

Scheib: Verh. der deutsch. Ges. f. Gyn., Band 12, p. 295, 1907; Deut- 
sche med. Wochens., No. 437, 1906. 

Schickele: Zentralblatt f . Gynakologie, No. 17, 1908. 

Schlafli: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 64, Heft 
1, 1909. 

Seeligmann: Zentralblatt f. Gynakologie, No. 5, 1907. 

Seitz: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 25, p. 
957, 1907; Zentralblatt f. Gynakologie, No. 17, 1907. 

Sellheim: Zentralblatt f. Gynakologie, No. 27, 1905; Deutsche med. 
Wochens., p. 888, 1907. 

Semmerlink: Zentralblatt f. Gynakologie, No. 48. 1906. 

Sigwart: Zentralblatt f. Gynakologie, No. 20, pp. 553, 1181, 1907, and 
No. 48, 1908. 

Stockel: Verh. der deutsch. Ges. f. Gj^n., Band 12, 1907; Zentralblatt 
f. Gynakologie, No. 3, 1906. 

Thies: Verh. der deutsch. Ges. f. Gyn., Band 12, p. 342, 1907; Zentral- 
blatt f . Gynakologie, p. 875, 1907 ; Archiv f . Gynakologie, Band 
84, p. 99, 1907. 

Toth: Zentralblatt f. Gynakologie, No. 49, 1908. 

Truzzi: Zentralblatt f. Gynakologie, No. 20, 1907. 

Tweedy: Journal of Obstetrics and Gynecology of the British Empire, 
May, 1907. 

Van de Velde: Verh. der deutsch. Ges. f. Gyn., Band 12, p. 270, 1907; 
Wiener m. Wochens., No. 29, 1907. 

von Elischer: Verh. der deutsch. Ges. f. Gyn., Band 12, p. 257, 1907. 

von Franque: Verh. der deutsch. Ges. f. Gyn., Band 12, p. 230, 1907.. 

Walcher: Zentralblatt f. Gynakologie, p. 929, 1907. 

Waldstein: Gyn. Rundschau, p. 34, 1907. 

Williams: American Journal of Obstetrics, August, 1908. 

Wilson: Obstetrical and Gynecological Section of the Royal Society of 
Medicine, London, October 10, 1907; Lancet, p. 1534, 1907;, 
Journal of Obstetrics and Gynecology of the British Empire,. 
January, 1908. 

Zangemeister : Zentralblatt f. Gynakologie, No. 48, 1906. 

Zweifel: Verh. der deutsch. Ges. f. Gyn., Band 12, p. 33, 1907; Zen- 
tralblatt f. Gynakologie, p. 163, 1907; Ann. de Gyn. et d'Obst., 
p. 531, September, 1907; Zentralblatt f. Gynakologie, No. 1„. 
1905, and No. 26, 1906. 



VAGINAL EXTRACTION PRECEDED BY SECTION 287 

VAGINAL EXTRACTION PRECEDED BY SECTION OF THE CERVIX, 
LOWER UTERINE SEGMENT, OR PERINEUM 

In cases where, through lack of development or stenosis from any 
cause, the lower portion of the uterus, the pelvic floor, or perineum 
may be so contracted as to make vaginal delivery dangerous, the birth- 
canal may be enlarged by section. Clinical observation has shown 
that a contracted cervix will often tear irregularly to a dangerous 
extent. This fact has led obstetricians at different times to incise 
the cervix, but it remained for Diihrssen to practice and devise deep 
incisions into the cervix to permit dehvery. These were made in the 
four quadrants of the cer^dcal circle, avoiding the lateral portions, the 
incisions being directed upward and outward at the outlet. They 
were carried to the vaginal junction and resulted in the immediate 
enlargement of the cervix. 

These incisions, however, did not reach sufficiently far to overcome 
entirely the resistance of the cervix, nor did they enter the lower 
uterine segment. Diihrssen, accordingly, developed the technic of 
wKat he termed "vaginal Cesarean section," which has now a recog- 
nized place among obstetric operations. 

Incision of the Cervix 

Incision of the cervix is justifiable where cervical tissue cannot 
be stretched without danger of extensive lacerations. AMiere the 
cer\dx dilates with difficulty, it will often tear irregidarly if stretched. 

A clean incision is safer than irregular lacerations, and hence it 
is justifiable to substitute the one for the other. 

Cases are sometimes seen where the external os can be found 
with difficulty from congenital occlusion. The writer recalls a case 
in which hemorrhage occurred during the first stage of labor, from a 
source not evident. The cervix was not dilated, although the 
patient had had considerable pain. The external os, upon ordinary 
examination, could not be found. On inspection an obUque tear 
in the substance of the cervix extended in an irregular manner to 
the vaginal junction, beginning J inch above the external os. This 



288 



OPERATIVE OBSTETRICS 



tear had opened small vessels, which bled freely. The external os 
barely admitted a grooved director, and was drawn upward and 




Fig. 176. — Incision of the cervix where the latter is taken up, but the os ex- 
ternum is only sUghtly dilated. Dark lines show direction in which incisions should 
be made (Kerr). 



backward so as to be scarcely accessible. The cervix was incised, 
when hemorrhage ceased and labor proceded. 



VAGIXAL EXTRACTION PRECEDED BY SECTION 289 

In practit^ing incision of the cervix the operator should have a 
clear view of the fii^ld of oi)eration. Blunt-pointed stout scissors 
should be used, and four cuts made extending to the vaginal junc- 
tion. The immediate opening of the cervix follows and usually 
the descent of the presenting part. After delivery the incisions may 
be closed by chromicized catgut. Even if this be not done, if the 
patient escapes infection, union usually takes place throughout the 
greater portion of the incision. 

Bibliography of Incision of Cervix and Perineum 

Aschoff : Monatsschrift f. Geburtshiilfe und Gynakologie, Band 22, Heft 

5, 1905. 
Brindau: Zentralblatt f. Gynakologie, No. 18, 1907. 
Diihrssen: Surgery, Gynecology, and Obstetrics, March, 1906. 
Jardine: Glasgow Medical Journal, 1907. 
Leopold: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 22, 

Heft 1, 1905. 
Lepage: Zentralblatt f. Gynakologie, No. 19, p. 545, 1907. 
Rouvier: L'Obstetrique, August, 1908. 

Vaginal Cesarean Section 

In vaginal Cesarean section incisions are carried through the 
cervix and lower uterine segment nearly to the lower border of the 
superior expulsive segment of the uterus. To permit this without 
injury to the bladder or peritoneum both must be pushed upward 
out of the way. 

The Technic of Vaginal Cesarean Section. — The patient is pre- 
pared as for any vaginal operation. The bladder is thoroughly emp- 
tied by catheter under anesthesia. The patient is placed on the 
edge of the table, her lower extremities flexed and rotated outward, 
and the cervix and surrounding tissues completely exposed by spec- 
ula. The cervix is strongly grasped by tenaculum forceps and 
drawn gently downward, and a transverse incision made in front 
of the cervix through the mucous membrane. With the finger, 
a blunt instrument, or blunt-pointed scissors the bladder and tissue 
beneath it is then pushed upward with the peritoneum; the lower 

19 



290 



OPERATIVE OBSTETRICS 



uterine segment then becomes visible. A longitudinal incision in 
the median line is then made through the narrow portion of the cervix, 
extending into or through the lower uterine segment. When the 
operation was first practised a similar incision w^as made in the pos- 
terior wall of the cervix, but this has been found to be rarely neces- 
sary. When the uterus is opened the presenting part comes into view 




Fig. 177.— Vaginal Cesarean section: Cervix drawn forcibly downward by volsella 
forceps. Longitudinal and transverse incisions in anterior vaginal wall. Lateral 
retractors used for purposes of illustration not necessary for operation (Peterson). 



or can readily be reached. Delivery is then effected, preferably 
by forceps, although version has been performed. Care is taken to 
deliver the child slowly and carefully to avoid lacerating the uterus. 
After the child is born the placenta is removed, usually manually^ the 
uterus emptied of clots, membranes, and amniotic liquid, and tam- 
poned with 10 per cent, iodoform gauze. The longitudinal incision 
in the lower uterine segment and cervix is first closed, followed by 



VAGINAL EXTRACTION PRECEDED BY SECTION 



291 



the uniting of the transverse vaginal incision The vagina is then 
moderately tamponed with bichlorid gauze. Where a posterior cer- 
vical incision is made, this is closed in th(^ manner described. 

The Indications for Vaginal Cesarean Section. — Some conditions 
which require the prompt emptying of the uterus, circumstances 
being favorable for vaginal delivery, indicate vaginal Cesarean sec- 




Fig. 178. — Vaginal Cesarean section : Vaginal wall dissected a\Yay from bladder 
wall for short distance on each side of incisions. Bladder dissected from uterus by 
few strokes with sponge (Peterson). 



tion. This method is often selected in eclampsia, in premature sepa- 
ration of the normally situated placenta, in threatened death of the 
mother from heart disease, in threatened occhision of the umbilical 
cord, and in the event of sudden death of the mother, the fetus sur- 
viving. 

Vaginal Cesarean section is not indicated in contracted pelvis, 
for it does not enlarge the pelvis. Its performance is an error under 



292 



OPERATIVE OBSTETRICS 



these conditions. It is also contraindicated in septic cases because 
it leaves the septic uterus in a condition favorable for the develop- 
ment of severe infection. It is also not indicated in overgrowth of 
the fetus or in considerable disproportion between mother and child, 
and its performance in these cases will be followed by disappoint- 
ing results. 




Fig. 179. — Vaginal Cesarean section: Cervix grasped at each side of median line 
by volsella forceps. Cervix split upward in median line by stout scissors. Bladder 
held up beliind pubes by retractor or sponge (Peterson). 



Complications Following the Operation. — The element of greatest 
danger in the operation is the occurrence of bleeding, which makes 
the development of septic infection an easy matter. It is not always 
easy to expose the field of operation to A^ision, and without such guid- 
ance the operator may carry the incisions further than is necessary, 
thereby opening into very vascular tissue, which bleeds easil}^ and 
tears readily during delivery. Wounds of the urethra and base of 



VAGIXAL EXTHACTIOX PRECEDED BY SECTION 



293 




Fig. 180. — Vaginal Cesarean section: Profile view, showing anterior cervical 
wall spKt upward as far as peritoneal reflexion. Same kind of incision can be made 
in posterior cervical lip (Peterson). 




Fig. 181. — Vaginal Cesarean section: Anterior cervical wall split upward. 
Membranes bulging downward. Through this opening child can be delivered by 
version or forceps (Peterson). 



294 



OPERATIVE OBSTETRICS 



the bladder, lacerations extending through the vagina into the 
pelvic and abdominal tissues, and their results have been observed. 

The advantages claimed for the operation are its rapidity, the 
fact that it avoids abdominal and peritoneal incision, that it is less 
formidable to patients than abdominal section, leaves no visible scar, 
the patient remaining in good condition after the operation. Those 
who advocate it most strongly have urged that it is suitable for per- 




^j|l»MjQ«Vv^ 



Fig. 182. — Vaginal Cesarean section: Forceps introduced through incision. It is bet- 
ter to incise posterior cervical wall than to have opening too small (Peterson). 

formance in private houses. Experience has shown that to be suc- 
cessful it requires hospital facilities and trained assistance. 

Vaginal Cesarean Section for Placenta Praevia.— Theoretically, 
vaginal Cesarean section would be indicated for placenta prsevia. 
In this condition, however, the cervix and lower uterine segment are 
more soft than normal and yield more readily to dilation. At 
present better results are obtained in placenta prsevia by dilating the 



VAGIXAL EXTRACTION PllKCKDEI) BY SECTION 



295 



cervix sufficiently to i)ennit the introduction of a dilating bag. This, 
folded, should be passed through the membranes or placenta, then 
distend al. It will make pressure upon the placenta, checking hemor- 
rhage and dilating the cervix for deliver^^ 

The Application of Vaginal Cesarean Section. — Retroflexion and 
incarceration of the pregnant uterus was successfully treated by 




Fig. 183. — Vaginal Cesarean section: Incision closed by continuous suture 
of chromicized catgut. Suture should pass down to, but not through, cervical 
mucosa (Peterson). 



Benecke.^ The pregnancy was five months advanced, the fetus had 
perished, the bladder had become infected, the cervix was dense 
and could be dilated with the greatest difficulty only. During the 
vaginal operation the l^ladder wall was opened, followed by the evac- 
uation of its contents. Lacerations were immediately sutured with 
catgut, the uterus emptied in the usual manner, incisions closed, and 

1 Zentralblatt f. Gyn., No. 23. 1906. 



296 



OPERATIVE OBSTETRICS 



the bladder permanently drained. The patient had a mild attack of 
cystiti?. but recovered. Holmes^ re^-iewing the operation up to 
date, believes that it finds its principal indication in rigidity of 
the cer^-ix, including the presence of scar tissue and carcinoma^ 
and in some cases of cer^^cal displacements. Zarate- performed 
vaginal Cesarean section tipon a patient who had narrowing of the 




Fig. 1S4. — Vaginal Cesarean section: Suture of cervical incision completed (Peterson). 



larynx from sear tissue, with consoHdation of the right lower portion 
of the limg. The lar^mgeal lesion was syphilitic. The mother's 
breathing was immediately improve<:l after the uterus was emptied, 
and she recoA'ered and was able to nurse the cliild. Dining her 
convalescence an examination of the lanmx showed characteristic 
lesions. Rotter^ performed the operation and delivered the child in 

^ Surgery-. G^iiecology, and Obstetrics, December, 1906. 
- Zentralblatt f . Gyn., Xo. 52, 1907. 
3 Ibid., Xo. 39: lf'07. 



VAGDCAL EXTR-\CTIOX PRECEDED BY SECT! 



297 



five minutes in a multipara djnng from mitral disea^k.- with e».lema of 
the limgs. The rapidity of the operation made it especially' appro- 
priate for such a case. In cases of eclampsia ^unconscious the opera- 
tion was ako performed without anesthesia. 

The criticisms on vaginal Cesarean section have arisen largely 
from an unfortimate choice in selecting cases for the operation. Its 




Fig. ISo— " -- 7 _ 

tmuous or inrrrrv t : : 

coaptation, for fear of oozing under flap (Peterson). 



field is limitetl, but at present it is useful in eclampsia, premature 
separation of the placenta, heart lesions, and other maternal diseases 
which may threaten immediate death during labor, and. rarely, in 
conditions threatening the fetus. The op)eration has been success- 
fully performed for prolapse of the umbilical cord through a ver\' 
resisting cenTx. 



298 OPERATIVE OBSTETRICS 



Bibliography of Vaginal Cesarean Section 

Benecke: Zentralblatt f. Gynakologie, No. 23, 1906. 

Bonnaire: La Presse med., Xos. 66 and 67, 1909. 

Bossi: Proceedings 16tli International Congress, Budapest, 1909; Gyn. 

Rundschau, No. 23, 1909. 
Biittner: Zentralblatt f. Gynakologie, No. 29, p. 918, 1907. 
Doderlein: Miinchener m. Wochens., p. 963, 1907. 
Diihrssen: Transactions of American Gynecological Society, 1908; Gyn. 

Rundschau, Heft 22, 1908; Beitrage z. Geb., Band U, 1909. 
Frieclmann: Gyn. Rundsch., p. 613, 1907. 
Fry: American Journal of Obstetrics, February, 1909. 
Fuchs : Monatsschrif t f . Geburtshiilfe und Gynakologie, Band 26, p. 295, 

1907; Zentralblatt f. Gynakologie, No. 6, 1909. 
Gauss: Proceedings 16th International Congress, Budapest, 1909. 
Goffe: American Journal of Obstetrics, August, 1905. 
Herz: Wiener med. Wochens., No. 5, 1907. 

Holmes: Surgery, Gynecology, and Obstetrics, December, 1906. 
Humpstone: American Journal of Obstetrics, Januar}^, 1909. 
Keyserhngk: Zentralblatt f. Gynakologie, No. 25, 1907. 
Kiistner: Zentralblatt f. Gynakologie, No. 36, 1909; Monatsschrift f. 

Geburtshiilfe und G^'nakologie, June, 1909. 
Muller: Zentralblatt f. Gynakologie, No. 11, 1907. 
Nacke: Zentralblatt f. Gynakologie, No. 6, 1909. 
Nadory: Zentralblatt f. Gynakologie, No. 39, 1907. 
Neumann: Archiv f. G3^nakologie, Band 79, Heft 1, 1906. 
Nijhoff : Zentralblatt f. Gynakologie, No. 46, 1907. 
Pape: Deutsche med. Wochenschrift, No. 39, 1907. 
Peterson: Surgery, Gynecolog}-, and Obstetrics, February, 1909. 
Pf annenstiel : Miinchener med. Wochenschrift, No. 19, 1909; Monats- 
schrift f. Geburtshiilfe und Gynakologie, Band 30, p. 630, 1909. 
Pforte: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 30, 1909. 
Rotter: Zentralblatt f. Gjmakologie, Nos. 32 and 39, 1907, and No. 49, 

1908. 
Scheib: Zentralblatt f. Gynakologie, p. 325, 1907. 
Sinclair: Journal of Obstetrics and Gynecology of the British Empire, 

April, 1906. 
Solms: Berliner klin. Wochenschrift, No. 5, 1909. 
Spaeth: Zentralblatt f. Gynakologie, No. 20, 1908. 
Sprigg: American Journal of Obstetrics, October, 1909. 
Staehler: Zentralblatt f. Gynakologie, No. 48, 1907. 
Walter: Hygiea, April, 1907. 



VAGINAL EXTRACTION PRECEDED BY SECTION 299 

Weisswanger: Zentralblatt f. Gynakologie, No. 10, lOOcS. 

Westphal: Zeiitralblatt f. Gynakologie, No. 28, 1906. 

\A'inter: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 26, 1907; 

Proceedings 16th International Congress, Budapest, 1909. 
Zarate: Zentralblatt f. Gynakologie, No. 52, 1907. 

Incision Into the Pelvic Floor and Perineum 
When it is evident that vaginal delivery must be attended by 
very severe laceration, such may be lessened or controlled by incis- 
ing the perineum and pelvic floor. Some have advocated central 
incision, producing a central laceration of the perineum extending 
to the sphincter of the bowel. The majority would practice what is 
called "episiotomy/' which incises the sphincter of the vagina, peri- 
neum, and pelvic floor. 

This procedure must be done under anesthesia, and is best accom- 
plished when the presenting part is pressing on the pelvic floor and 
when the perineum is drawn tensely against the fetus. If the patient 
is not to be anesthetized for delivery, she may be given partial anes- 
thesia and a probe-pointed knife or pair of blunt-pointed scissors 
inserted between the presenting part and the perineum, between the 
junction of the upper third and lower two-thirds of the lateral sur- 
face of the posterior segment of the pelvic floor. During a pain the 
cutting edge of the knife or scissors blade may be turned against the 
tense tissue, and allowed to cut through obliquely down and outward. 
It is rarely necessary to make the incision more than 1 inch in length ; 
sometimes two, J inch on each side, give better results. 

Immediately following this incision the posterior segment of the 
pelvic floor moves downward and backward and the tissues gape 
asunder, leaving a triangular wound whose apex is directed upward 
toward the cervix, and whose base extends along the lateral wafl of 
the birth-canal. Bleeding is rarely considerable after this incision, 
and if small vessels have opened, they should be tied with fine catgut. 
After delivery two lines of suture will be necessary to accuratety close 
the incision : one upon the outer perineal surface and the other upon 
the inner vaginal surface. If the tissues have separated deeply, it is 



300 OPERATIVE OBSTETRICS 

well to insert buried stitches of catgut to bring the parts together 
accurately. 

Complications rarely occur from these incisions, union is usually 
primary, and serious laceration of the pelvic floor and perineum is 
undoubtedly prevented by this means. 



Delivery by Abdominal Section 

Next to the introduction of antisepsis in obstetrics, the most 
important advance has been in the development of delivery by ab- 
dominal section. This has substituted certainty for uncertainty, 
shortened suffering greatly, robbed contracted pelvis of its terrors, 
given much better control of hemorrhage, and saved the lives and 
health of many mothers and children. The application of the prin- 
ciples of surgery to obstetric practice has been of as great value as 
the use of the same principles in general surgery or in various surgical 
specialties. 

When a method of treatment becomes successful it is often mis- 
apphecl, improperly used, and with bad results. Such has been the 
lot of deliver}^ by abdominal section. It has been wrongly applied 
to cases neglected and maltreated during labor, where the patient's 
Ufe had practically been lost before the operation was chosen. There 
is need to scrutinize the indications for abdominal delivery and to 
limit the operation to those conditions in which it is successful. If 
this be done the mortality and morbidity of difficult parturition will 
be greatly lessened. 

Methods of Abdominal Delivery. — When the fetus is in the uterus 
and it is to be delivered by abdominal section, methods of treatment 
msLj be chosen in accordance with the decision to render the patient 
incapable of further procreation or to avoid disturbing this import- 
ant function. The condition of the bod}^ of the womb is also a most 
important factor, for in the presence of extensive disease of the uterine 
muscle the womb must be removed, and the patient so rendered 
sterile. 



CELIOHVSTEUOTOMY 301 

CELIOHYSTEROTOMY 

By this tc^nii is understood the ()i)eiiing of the abdonion, the 
opening of the uterus, the removal of its contents, and the closure 
of the abdomen and womb. The patient is left capable of further 
procreation and but little, if any, change is made in the condition 
of the uterus. This operation is most often performed and is most 
frecjuently termed what is popularly called 'Cesarean section." 

The Indications for Celiohysterotomy. — It cannot be too clearly 
understood that celiohysterotomy must be a primary operation. 




Fig. 186. — Celiohysterotomy: The uterus turned out of the abdominal cavity. 
To distinguish the hands of the operator, they are covered by rubber gauntlets; 
the hands of the assistants are shown without them. 

There must have been no previous attempt to deliver the mother, no 
frequent vaginal manipulations, no pre-existing septic condition of the 
birth-canal. Mother and child must be in good condition. The 
previous application of forceps, attempts at version, prolonged vaginal 
examinations, efforts to dilate the cervix, septic conditions in the 
vagina, the fetus exhausted by birth pressure, these are among the 
most important contraindications for celiohysterotomy. For the 
operation to be successful the surroundings must be favorable. Al- 



302 OPERATIVE OBSTETRICS 

though it is better to have the patient in a hospital, the operation can 
be successfully done in a private house which is in good sanitary con- 
dition. The operator must be familiar with obstetric surgery and 
must understand thoroughty the principles of the operation. He 
must have two, preferably three, competent assistants. If the opera- 
tion is to proceed smoothly, there must be three experienced nurses. 
Spectators often think that cehohysterotomy is a very simple perform- 
ance. This may be so when the operation is done by experienced 








Fig. 187. — Celiohysterotomy : Incising the uterus. ^ 

persons with competent assistants, each of whom knows exactly his 
part in the operation. When these conditions are absent, celiohys- 
terotomy is by no means simple or easy. 

When the operator finds that the conditions which make the opera- 
tion justifiable are present, he may consider the indications for its 
employment. That most frequently existing is disproportion between 
the mother and child or physiologic incompetence for labor; concern- 
ing these indications there is but little difference of opinion. 

The application of the operation has been further extended to 



CKLIOHYSTHUOTOMY 



303 



central placenta pnevia, eclampsia, and threatencnl occlusion of the 
umbilical conl. In deciding upon the operation it must be remem- 
bered that in many cases it is a child-saving operation; hence its best 
results will not be obtained unless the child is viable and in good 
condition. 

The Technic of Celiohysterotomy. — The patient is placed upon her 
back upon a suitable table and the pelvis slightly raised. Care should 
be taken that the position of the patient's head is an easy one and that 




Fig. 188. — Celiohysterotomy: The delivery of the child. An assistant is con- 
trolling the hemorrhage by grasping the broad Hgaments. 



respiration is unimpeded. The bladder should be thoroughly emptied 
by catheter under anesthesia, just before the abdominal incision is 
made. In contracted pelves the bladder may be pinched between the 
presenting part and the pubes, and drawn upw^ard into the abdominal 
cavity. The abdominal incision is made in the median line, at first 
just below the umbilicus. This enables the operator to avoid the 
bladder, ascertaining by his fingers its position. The abdominal 
wall is often very thin in pregnancy, and care must be taken lest 



304 



OPERATIVE OBSTETRICS 



the incision pass through the abdominal wall and wound the uterus. 
The abdomen having been opened, and a careful examination made 
to ascertain the position of the bladder and intestines, the abdominal 
incision is then enlarged sufficiently to permit the removal of the 
uterus from the abdominal cavity. 

The advantages of this procedure are: a more efficient control 
of uterine contraction, the better avoidance of contaminating the 
abdominal cavity with amniotic liquid and blood, and better access 
to the uterus for the application of sutures. 




Fig. 189.— Celiohysterotomy: Pouring sterile salt solution through the recently 

emptied uterus. 

The disadvantages are: the danger of abdominal incision, the 
greater disturbance of the abdominal viscera, and the greater tendency 
to escape of the intestines from the abdomen. In the opinion of the 
majority of operators the advantages of removing the uterus from 
the abdominal cavity outweigh the disadvantages, and this manipula- 
tion is commonty practised. 

During the removal of the uterus from the abdomen considerable 
interference with respiration may arise because of the disturbance to 



CELIOHYSTEKOTOMY 



305 



the abdominal viscera. The anesth(^tizer should be prepared for 
this, and should vary the (luantity of ether used, and, if necessary, give 
appropriate stimulation, ^^'hen the uterus is delivered, res})iration 
is usually better, as the action of the diaphragm is less restricted. 
AVhen the uterus is eviscerated, a large soft pad or towel, thoroughly 
sterilized and warm, should be placed over the intestines and the al)- 
dominal walls brought together as far as possible without suture. 
The uterus may rest upon the hot moist pads and abdominal wall. 




Fig. 190. — Celiohysterotomy: Closing the uterine incision. 

To control hemorrhage from the uterus an assistant, preferably, 
grasps the broad ligaments with the thumb and fingers. If he is 
not experienced in this, he may simply grasp the lower uterine seg- 
ment with both hands encircling the lower part of the womb, the ulnar 
border of the hands being pressed inward at the sides of the uterus. 
A firm grasp should be exercised and hemorrhage prevented by pres- 
sure upon the uterine arteries and their anastomoses. 

When the uterus is ready for incision an assistant stands at the 
side of the operator with a sterile sheet or blanket in which to receive 
the child. The uterus is usually opened upon the anterior surface in 

20 



306 



OPERATIVE OBSTETRICS 



the median line by a longitudinal incision terminating about 1 inch 
below the fundus. Care should be taken not to open the uterus 
through the lower uterine segment. The operator should not make 
the incision the full length desired, because the uterine muscle will 
gape asunder as incised, and he may enlarge the incision slightly 
with the fingers before extracting the child 

During delivery the uterus may be slightly enlarged by laceration. 
Should this be serious, it might be necessary to sacrifice the womb. 




Fig. 191. — Celiohysterotomy: The uterus closed and contracted. 

The operator can learn by experience only how to proportion the uter- 
ine incision to the condition of the uterine muscle and the probable 
size of the child. The uterus should be opened with very light strokes 
of the knife, and if the membranes have not been ruptured, the 
opening may be completed by the fingers. If unruptured, the mem- 
branes should be broken and the amniotic liquid allowed to escape 
upon sterile towels placed beneath the womb. The operator then 
grasps the nearest available portion of the fetus, usually the lower 
extremities, occasionally the hips, and delivers the child slowly and 
carefully, to avoid tearing the womb. It is held head downward and 



CELIOHY.STEROTOMY 



30: 



the cord clanipcHl twice and cut between the clamps. The child is 
then given to an assistant for further care. 

Grasping the cord in the left hand, the operator then deliberately 
separates the placenta, removing placenta and membranes slowly 
and carefully. The uterus is also emptied of blood-clots. Hot 
sterile salt solution is then poured into the wonili tlirough the incision 
and allowed to run through the cervix into the vafrina. 

The uterine muscle is then closed by bringing together the muscle 
separately and reinforcing this with continuous suture of the uterine 





Yi^. 192. — Celiolivsterotomv: The abdomen closed. 



peritoneum. For the first is to to be preferred the best quality of 
silk, medium-sizeMil, which has recently been sterilized by boiling. 
With a curved needle stitches are inserted ^ inch from the border 
of the uterine incision beneath the peritoneal covering of the 
uterus, carried through the muscle, avoiding the linino- mem- 
brane of the womb, and inserted upon the opposite side and 
brought out. Stitches should be tied immediately after inser- 
tion with moderate firmness. They should be placed sufficiently 



308 OPERATIVE OBSTETRICS 

close together to accurately and firmly close the uterine muscle. 
Should a large uterine sinus be evident in the incision and bleed- 
ing, an oblique stitch through the muscle may be inserted. Of 
the value of this precaution the writer can speak from experience. 
During the insertion of the muscular stitches the patient should 
receive a tonic dose of strychnin and ergot hypodermically given. 
If there is much bronchial irritation with catarrh, atropin should also 
be given hypodermically. Contraction of the uterus may also be 



Fig. 193. — Celiohysterotomy: Applying the abdominal dressing. 

expedited by enveloping it in a hot towel wrung out of sterile w^ater, 
and massaging the uterus gently but rapidly. These measures have 
not failed so far, in the writer's experience, to secure uterine contrac- 
tion. 

When the muscular stitches have been inserted and tied, the 
uterine peritoneum should be closed with continuous suture of 
fine silk or No. 2 catgut, completely burying the muscular sutures. 
This suture should include not only the peritoneum, but subperi- 
toneal and some muscular tissue. The edges of the peritoneum 
should be turned inward and brought together. This suture forms 



CELIOHYSTEROTOMY 309 

a most efficient reinforceiiu^iit to the uterine suture. The uterus, 
having been satisfactorily closed, is then replaced in the abdominal 
cavity in its normal position, and the intestines and omentum allowed 
to resume their normal positions. When it is certain that no 
foreign body has been left in the abdomen, a moderate quantity of 
sterile salt solution is introduced into the abdominal cavity and 
the abdominal wound closed. This is effected by bringing together 
separately the peritoneum with fine catgut or fine silk. In preg- 
nancy the abdomen is often so distended that it may be impossible 
to distinguish the different layers of tissue in the abdominal wall. 
Where the abdomen is thin the suture which closes the peritoneum 
must include the muscular fascia of the abdomen as well. A good 
scar follows such suture, although it is not as exact as the method 
of suturing the different tissues separately. The skin is then brought 
together with interrupted silkworm-gut stitches. 

The abdominal dressing after celiohysterotomy is of considerable 
importance. The incision is a long one, the abdominal wails have 
been overstretched and must undergo involution, and the abdomi- 
nal wound might readily burst asunder if the patient were to cough 
or vomit violently. In addition to accurate suture a thoroughly 
secure dressing must be applied and maintained securely in position. 
It is furthermore desirable to make pressure on the solar plexus fol- 
lowing the emptying of the uterus. This is necessary to maintain the 
tone of the abdominal viscera. We have had satisfactory results 
with a dressing appHed as follows: 

Above the fundus of the uterus a pad of sterile gauze, wide 
enough to extend across the abdomen and several inches thick, is 
placed. Over the incision sterile gauze is applied in several layers, 
and then the usual gauze and cotton pads, employed after abdominal 
section, are applied. Strips of rubber adhesive plaster, from 2 to 
3 inches wide, are then placed over this dressing, making pressure 
from above do\ATiward. These should make firm but gentle pressure, 
the edges overlapping and forming one continuous occlusion bandage, 
which cannot be loosened by straining or coughing. Over this is 



310 OPERATIVE OBSTETRICS 

placed a many-tailed binder of flannel. In uncomplicated cases 
this dressing remains from ten days to two weeks without dis- 
turbance. 

Complications Arising During Celiohysterotomy. — In operating 
for contracted pelvis, the obstetrician should not lose sight of the 
danger of wounding the bladder because of its high position in the 
abdomen. The writer has seen the bladder, although emptied by 
catheter, within an inch of the umbilicus in contracted pelves in highly 
deformed w^omen ; the intestine may be distended with gas at the time 
of operation, and a large portion of it may escape from the abdominal 
cavity. This, in our experience, has never caused serious trouble, 
and has not led us to alter our plan of operation. Amniotic liquid, in 
part, may escape into the abdominal cavity. This has happened but 
rarely in our experience and has produced no bad results. The uterus 
may show a disposition to remain relaxed, with more or less hemor- 
rhage. As we have stated, we have seen no case in which this was not 
overcome by the hypodermic administration of strychnin and ergot, 
by pouring hot salt solution through the uterus, and by massage. 
As an added precaution we have several times tamponed the uterine 
cavity with 10 per cent, iodoform gauze, passing the gauze downward 
through the cervix into the vagina. This gauze should be removed 
in from forty-eight to seventy-two hours after the operation. Should 
the patient become partially conscious during the operation and 
struggle, she might cause tear of the uterine muscle at the moment 
when the child was delivered. If this tear was extensive, cehohys- 
terectomy might be indicated. 

Celiohysterotomy in Suspected Cases. — In cases which have 
been long in labor, and under circumstances where infection may 
readily have occurred, if the necessity for celiohysterotomy arises the 
operator must take unusual precautions to guard against the devel- 
opment of infection. The decision to save the uterus and the 
patient's power of procreation is often a very difficult one to make. 
If the membranes are unruptured at the time of operation the prob- 
lem is much more simple, and unless the conditions under which the 



CE L I OH Y .ST E II OT O M V ;i 1 1 

patient has been during labor arc unusualh' bad the effort should 
be made. 

Before operation the vagina should be thoroughly irrigated with 
1 per cent, lysol, the external parts thoroughly cleansed with tincture 
of green soap and hot water, and then with bichlorid solution (1 : 2000). 
Especial care must be exercised when the uterus is removed from the 
abdomen to protect the abdominal cavity by large pads wrung out 
of hot sterile salt solution. After the uterus has been emptied it 
should be thoroughly irrigated by pouring salt solution through it, 
and then the uterine cavity should be packed with 10 per cent, iodo- 
form gauze, the end of which is carried through the cervix into the 
vagina. Before the abdomen has been closed a moderate quantity 
of salt solution should be poured into the abdominal cavity. The 
vagina should also be tamponed with bichlorid gauze. 

If the membranes have long been ruptured before operation, and if 
the interior of the uterus is foul in odor and greenish in color, the 
Porro operation should be selected. 

The gauze may be removed in forty-eight to sixty hours and the 
vagina sponged with cotton in bichlorid solution (1: 4000). 

The After-care of the Patient. — ^As soon as the operation is com- 
pleted the patient should be drawn to the edge of the table, the 
external parts made thoroughly aseptic, and the vagina sponged out 
with cotton dipped in bichlorid solution (1 :4000). Some clotted 
blood often remains in the vagina after operation, and this should 
be removed. Xo other vaginal manipulation or douching should be 
practised during the patient's recover}-. The catheter should be 
employed every six hours, so long as necessary. If the patient had 
been in the hospital some time it would be unnecessary to move her 
bowels after the operation for forty-eight to seventy-two hours. 

Many cases of deliver}' by abdominal section are performed upon 
patients who have had no suitable preparation, and all pregnant 
patients have a tendency to constipation, hence we have found it 
wiser, in the majority of cases, to purge the patient within forty- 
eight hours after delivery. Immediately after the operation the 



312 OPERATIVE OBSTETRICS 

patient should have, if necessary, a hypodermic injection of mor- 
phin (J gr.). If atropin is needed it may be given. Sips of hot 
water, if the patient will take it, with 10 drops of aromatic spirits 
of ammonia, will usually be advantageous. If the patient vomits 
severely, the stomach should at once be thoroughly washed out. 
Should abdominal distention occur, a high irrigation of the bowel 
with hot salt solution should be practised The patient should not 
lie upon the side for the first twenty-four hours, but the limbs may be 
flexed and the patient made as comfortable as possible. If she 
complains of tightness in the bandage, the nurse may very slightly 
cut the border of the adhesive straps, taking care not to lessen it 
essentially, but to let the patient see that the endeavor is made. 
When the mother has thoroughly recovered from the operation she 
should nurse the child, at first once in eight hours or twelve, then 
every four hours. 

When the patient has recovered from the anesthetic she may 
be given calomel in J-gr. doses hourly until eight have been taken. 
This should be combined with sodium bicarbonate and taken with 
water, or with albumen-water. From four to six hours after this 
has been finished, she may take a saline, followed by a high purga- 
tive enema. After the bowels have moved thoroughly she may 
take liquid food every three hours, gradually increasing as appetite 
returns. 

The Care of the Child. — At the moment of delivery the child often 
shows a disinchnation to breathe. This seems to be a physiologic 
apnea, possibly influenced somewhat by the anesthetic. Folding 
and unfolding the child head downward, its mouth and nostrils 
efficiently cleansed with antiseptic fluid, will usually cause it to 
breathe normally. We have, in our experience, seen no fetus fail 
to breathe which was in good condition at the time of operation. 
The child is usually vigorous, showing absence of birth pressure in 
the shape of the cranium. Until the mother's appetite returns and 
she can take food, the child may be fed with modified milk, with al- 
bumen-water, and small doses of brandy well diluted. If it has colic, 



CELIOHYSTEROTOMY 313 

the intestines should be washed out. As the mother's ability to take 
nourishment increases, she should niu-se the child more freciuently. 
The operation does not interfere in the least ^ith lactation, and 
mother and cliild usually do well. 

General Care of the Mother. — At first stn'chnin in jirg^- doses 
is given h}-podermicaDy, every three to six hours, imtil the patient's 
bowels have moved thoroughly and she is able to take and retain 
food. Stn'chnin is then continued by the mouth for the first ten 
days. If there is much sleeplessness and pain, codein is given in J- 
gr. doses. Sterile \'ulvar dressings are worn by the patient, and 
after the first few days she may turn upon her sides as often as desired. 
In uncomplicated cases the dressings are changed two weeks after 
the operation and silkworm-gut stitches removed. A second set of 
adhesive straps are applied and allowed to remain for another ten days. 
These are then removed and a belt fitted, and thi'ee weeks after the 
operation the patient may sit up and gradually walk about. She can 
usually go to her home four weeks after section in good condition. 
Alany operators discharge patients after section much sooner, but we 
have kept them imder observation as long as possible in their inter- 
est, and because we wished to accurately study the results of the 
operation. In 95 cases we recall but one hernia, and this not an ex- 
tensive one. These patients suffer no complications with the breasts, 
except those which may arise after any confinement. 

Complications During the Puerperal Period. — Acute dilation of 
the stomach and intestines from pre-existing acute toxemia may 
result fatally. In these cases the patient vomits repeatedly and, in 
spite of treatment, the stomach and large intestine become so greatly 
distended as indirectly to bring about cessation of the heart's action. 
Hemorrhage may occur from the slipping or imtying of a stitch in 
the uterine muscle. The patient may cough or vomit and biu^ open 
the abdominal incision. "VMiere this occtured, a knuckle of intestine 
protruded, the peritoneiun became infected, and sepsis restilted. 
Thrombosis and embolism are not common after celiohysterotomy. 
Pneumonia is not often obser\'ed, nor is acetonemia. Stitch-hole 



314 OPERATIVE OBSTETRICS 

abscess may develop in cases where efforts have been made to deliver 
before the operation, thus infecting the interior of the uterus. One 
of the writer's cases, a girl with highly contracted pelvis, did not wish 
to recover rapidly after the operation, because while well she was 
obhged to work. She smeared her fingers with lochial discharge, dis- 
placed her bandage, and infected several stitches of the abdominal 
wound. She accomplished her purpose, but ultimately made a 
good recovery. Septic infection may develop after cehohysterotomy 
from instruments, hands, sutures, sponges, and surroundings at the 
time of operation, from the Bacillus coh communis in the intestine 
of the patient, and from unknown sources. Thus the writer lost one 
case from infection of the peritoneum with the Bacillus proteus atiI- 
garis. The source of this infection we could not determine, as suture 
material was found to be sterile, and the usual antiseptic precau- 
tions had been taken. 

DELIVERY BY ABDOMINAL SECTION WITH STERILIZATION 

It may, for many reasons, be desirable that the patient be not again 
exposed to the danger of childbirth. 

Under these circumstances sterihzation may be effected by one 
of several methods. 

The excision of the uterine end of the Fallopian tubes, removing 
a considerable portion of the tube, is efficient. Ligation only of the 
Fallopian tubes has been found untrustworthy and has been aban- 
doned. At the conclusion of cehohysterotomy a V-shaped incision 
may be made into the uterine cornu, removing not only the entire 
portion of the tube, but also a portion of the uterine wall at that 
point. The wound thus made should be closed by buried catgut 
stitches, and the peritoneum covering the uterus united above it. 
An inch of the Fallopian tube should be removed and the proximal 
end hgated securely. This procedure has given good results without 
comphcations. Menstruation continues, as the ovary is not inter- 
fered with, but impregnation is impossible. 



CELIOHYSTEKECTOMY WITH IXTRAPELVIC TREATMEXT OF STUMP 315 

CELIOHYSTERECTOMY WITH INTRAPELVIC TREATMENT OF THE 

STUMP 

When, however, the body of the uterus is diseased, or ovaries or 
Fallopian tubes are abnormal, or it is desirable to end not only repro- 
duction but menstruation, the removal of the ovaries, tubes, and body 
of the womb is indicated. There is nothing gained by dissecting out 
the cervix, as it serves a useful purpose in closing the vault of the 
vagina. 

The Indications for Celiohysterectomy With Intraperitoneal Treat- 
ment of the Stump.— This operation is to be advised where it is 
desired to remove from the patient the body of the uterus, ovaries, 
and Fallopian tubes. If the patient be in a highly infected condition, 
the stump should not be dropped, but the body of the uterus should 
be removed and the stump treated outside the peritoneum. It 
may, in some of these cases, be possible to save the womb by per- 
forming suprasymphyseal section and draining the uterus through 
the abdominal wound with gauze. Celiohysterectomy with dropping 
of the stump is also indicated in patients where sterilization is de- 
manded, and where the circumstances of the patient are such that 
she should be placed beyond the danger of disease of the pelvic organs. 
Thus, in women near the menopause, in the very poor who can least 
afford to be ill, in those deficiently developed mentally, who should 
not reproduce their kind and who are Hkely to be a charge upon the 
community, and in healthy married women who elect the operation 
to avoid impregnation and pelvic disease, the operation will give good 
results. 

The Technic of the Operation. — The patient is prepared as usual 
for abdominal section and the vagina is also prepared for operation. 
But very snght dilation of the cervix is required, as there is little 
or no discharge through the stump after the operation. Hence, in 
multiparse and in primiparse where the cervix is softened and shortened 
the operator need not wait for labor. 

The patient is placed upon her back with the pelvis slightly 
raised, the abdomen is opened, and the uterus deUvered through the 



316 



OPERATIVE OBSTETRICS 



abdomen^ as in celiohysterotomy. After protecting the intestines 
with warm moist towels, the uterus is opened across the fundus, 
longitudinahy or transversely, widely enough to permit the quick 
extraction of the child. After the delivery of the child it is usually 
convenient to deliver the placenta. Hemorrhage is controlled during 
delivery by pressure upon the vessels in the broad ligaments, as in 
celiohysterotomy. 




Fig. 194. — Poorly developed cretin dwarf delivered by celiohysterectomy. 

The operator then begins upon one side of the pelvis and clamps 
the broad ligament along the side of the pelvis external to the ovary 
and tube. The broad ligament and ovarian arteries are then tied 
and the tissue in the grasp of the clamp severed from that which has 
been ligated. The round ligament and small vessels in its vicinity 
are similarly tied and the uterine arteries are sought and ligated. A 
slight incision is then made encircling the uterus through its peri- 
toneal tissue at the lower uterine segment, when the peritoneal tissue 
is pushed downward. The uterus is then amputated through the 



CELIOHYSTERECTOMY WITH INTKAPELVIC TREATMENT OF STUMP 317 

lower segment and bleeding vessels are caught and tied. If the 
uterine stump is of considerable thickness it is well to bring its sur- 
faces together with buried stitches of catgut. Beginning at one 







^» 



* 



r ■4#'i 



'. Ti^ 




Fig. 195. — Infant born by celiohysterot- Fig. 196. — Flat pelvis; celiohysterotomy. 
omy; rachitic pelvis. 

side, the peritoneal layers of the broad ligament are then brought 
together by continuous suture, covering the uterine stump with peri- 
toneum, and passing completely across and around the pelvis. The 
pelvis is thus left with no tissues uncovered with peritoneum, hemor- 



318 



OPERATIVE OBSTETRICS 



rhage is completely arrested, the bladder and rectum remain in normal 
position, and the remains of the broad ligaments hold the stump in 
place at the top of the vagina. The abdomen is closed without drain- 
age, a pint of salt solution being left within the cavity. The ab- 




Fig. 197. Fig. 198. Fig. 199. 

Figs. 197, 198, and 199.— Achondroplasia. Repeated Cesarean section. First, 

celiohysterotomy; second, ceKohysterectomy. 

dominal dressing is the same as for celiohysterotomy and the after- 
treatment essentially the same. The duration of the operation is 
slightly longer than celiohysterotomy, but not sufficient to cause the 
patient danger. Patients bear both operations equally well. 

The Puerperal Period After Celiohysterectomy. — The mother 



CELIOHYSTERECTOMY WITH INTIIAPELVIC TREATMENT OF STUMP 319 

nurses the child as well as if the uterus, tubes, and ovaries had not been 
removed. Lactation will proceed much longer than when the 
ovaries have been left and menstruation returns. In six months 




Fig. 200. 



Fig. 201. 



Fig. 202. 



Figs. 200, 201, and 202. — Rachitic pelvis. Celiohysterotomy, showing condition of 
the patient, with recoveiy. 



or a year after the cessation of lactation the patient may be troubled 
by flashes of heat and some of the disturbances incident to the meno- 
pause. These however, usuelly subside without difficulty. 



320 OPERATIVE OBSTETRICS 

Complications of the Operation. — In experienced hands the opera- 
tion is very satisfactory. With incompetent operators, one or both 
ureters have been tied or cut in the effort to Ugate securely the uter- 
ine arteries. Occasionally necrosis of the stump occurs, and its 
mucous membrane and submucous tissue may come away with the 
discharge of mucopus through the vagina. Rarely a vessel of 
the broad ligament may be wounded and a hematoma may form. 
In one instance in the experience of the writer it was necessary to 
incise this and empt}^ it through the vagina. This patient recovered. 

The Results of Celiohysterectomy. — In the experience of the WTiter 
and other operators celiohysterectomy gives excellent results. Pro- 
lapse and hernia do not occur and the patient is left in excellent physi- 
cal condition. For the child the operation is a life-saving one, and as 
it may be performed before labor the child is subjected to no birth 
pressure whatever. 

CELIOHYSTERECTOMY WITH EXTRAPERITONEAL TREATMENT OF 
THE STUMP (PORRO^S OPERATION) 

For fibroid uteri, and in pregnancy complicated with contracted 
pelvis, Porro performed hysterectomy followed by the suspension of. 
the stump at the lower end of the abdominal incision, and the removal 
of the greater portion of its tissues by sloughing. In the light of 
modern technic the operation is objectionable, because the conva- 
lescence of the patient is much prolonged and because it leaves a 
sloughing mass upon the patient's abdomen. Practically, the opera- 
tion is valuable in septic cases because it promptly removes the 
most severely infected portion of the birth-canal (the uterine body), 
it can be quickly performed, and its technic is better adapted to those 
not accustomed to abdominal surgery. Experience has shown that 
it is safer to leave a septic stump at the lower end of the abdominal 
incision than to drop it, although covered by peritoneum, into the 
pelvic cavity. Hence, undesirable as the operation may seem to be, 
technically speaking, it should still have a place in obstetric surgery. 

Indications. — ^The indications for celiohysterectomy with extra- 



celiohystekecto.my: extkapkuitoxeal tueatmext of stump 321 

peritoneal treatment of the stump are concliticns rendering vaginal 
delivery dangerous in a woman whose uterus is severely infected. 
In cancer of the uterus the entire womb must be removed ; in fibroid 
uterus it is better to leave the cervix, and in ruptiu'ed uterus it is 
usually best to leave the cervical stump to close the vagina. The 
Porro operation is sc^lectcMl to remove the infected bod}^ of the womb. 




Fig. 203. — Porro operation: Clamps and stump in the lower end of the abdominal 

incision. 



The Technic of the Operation. — After the womb has been emptied 
by abdominal section, if the operator has time he should ligate 
securely the ovarian and round ligament vessels. The broad ligament 
should be seA^red as far as the ligatures control hemorrhage. One 
or two clamps are then placed transversely across the lower uterine 

21 



322 



OPERATIVE OBSTETRICS 



segment, accurately grasping the entire width of the lower segment. 
They are securely fastened. These clamps will extend across the ab- 
domen, holding the stump above the level of the abdominal surface. 
The tubes and ovaries are brought upward and removed with the 
body of the womb. The broad ligaments are closed so far as is neces- 




Fig. 204. — Porro operation: Stump separated. Tissues healing. 



sary, although but little tissue remains which is not in the grasp of 
the clamp. The uterus is amputated transversely above the clamp, 
and the stump is trimmed as accurately as possible to remove all super- 
fluous tissue. The abdominal peritoneum is then accurately closed 
from above downward, and stitched to the peritoneal covering of 
the stump through its entire circumference, thus shutting off the 



celiohystekectomy: extraperitoneal treatment of sTUAir 323 

peritoneal cavity from the necrotic area in the stump. The skin is 
brought together with interrupted silkworm-gut stitches and the cut 
surfaces of the stump freely powdered. The handles of the clamps 
are then wrapped in gauze to support them on the patient's abdomen, 
and the cut surface of the stump is freely powdered with iodoform 
(10 per cent.), and boric acid. An abdominal dressing with adhesive 
strips is so applied that the lower portion can readily be opened to 
permit frequent dressing of the stump. 




Fig. 205. — Porro operation: Stump separated. Tissues healed. 



The Recovery from Celiohysterectomy with Extraperitoneal Treat- 
ment of the Stump (Porro's Operation). — The patient's recovery is 
retarded by the sloughing away of the tissue enclosed within the 
clamp. In two weeks the tissue is so softened that the clamps can 
usually be trimmed away wTth dull scissors. 

There is a depressed healing surface, varying in size according to 
the size of the uterus. This does not suppurate, as a rule, and under- 
goes granulation and contraction if kept clean. Ultimately the 



324 OPERATIVE OBSTETRICS 

patient has a firm, tough scar, depressed somewhat below the surface 



JEFFERSON MEDICAL COLLEGE HOSPITAL. 



^ 



Pati 

PHYS 

Intern 



ARTOF_BLOOD PRESSURE, PULSE AND RESPIRATION. 

ENT'S NAME .C liiW i^lC^J #t J /^]» JAMtll »"1^ OPERATION .^J^Uy4yU^^,,^l^..y^^ 
5.C.AN-S NAME.i!(?.a4^.<K^ ^ AN ESTH ET.C USED (S^lS^^ /i'^^ 

e;5 name J^,i....'tc,..cJu^.^^^ T.ME TO f<u^sTH^r^z^JM-£l'^M'.'?T^'^ 



Duration of operation 



B P 

MMHG 

240 
230 
220 
210 
200 
190 
180 
170 
160 
»50 
140 
130 
120 

up 

100 
90 
80 
70 
60 
50 







--j r+rf<»"^j"^ sr's' fjvc^t ^r^p 



...l_ 







l±i±l±tHi: 

: ! I ' ! I i ! 






1-1' 



'+ 






-L-i-L 



! I 



-I — 



T'l 



1-4-4- -4-i-4-l- 



m 



-r-i--rT--rTi 

"R+ii-i= 



I I 



PULSE 


RESP. 


190 




ISO 






40 


170 




160 




150 


35 


140 




130 






30 


120 




1 10 




100 


25 


90 




80 






20 


70 




60 




50 


15 


40 




30 






10 


20 




10 




5 


5 



CONTINUOUS OH BLACK Ll N r = BLOOD PRESSURE 
INTERHUPTEO OR RED LINE = PULSE. 
' DOT AND DASH OR BLUE LINE = RESP. 



Fig. 206. — Chart of blood-pressure during Porro operation. 



of the abdomen and firmly holding the cervical stump and the upper 
portion of the vagina. While the operation is somewhat unsatisfac- 



CELIOHYSTEKECTOMV: EXTRAPERITONEAL TREATMENT OF STUMP 325 



tory, techiiicaily si)eakiiig, aiul :<liould not be selectetl in clean cases, 
in infected cases, clinically it gives good results. 

Complications of Celiohysterectomy with Extraperitoneal Treat- 
ment of the Stump (^Porro's Operation). — In some of the early cases 



^ ♦ 



p- ^ 



^ 





Fig. 207.— Porro oper- Fig. 208.— Porro op- Fig. 209.— Result of 

ation: Patient with ky- eration: Kyphotic peh'is, Porro operation: Kyphot- 
photic pelvis. rear view. ic pelvis. 

the patient died after this operation from hemorrhage, caused by 
sUpping of the clamps, or through means employed to check hemor- 
rhage. Porro first used two stout pins introduced at right angles 
through the stump, around which was drawn tightly a figin-e-eight 
ligature. Koeberle applied a loop of wire tightly around the stump, 



326 



OPERATIVE OBSTETRICS 



compressing the stump by tightening the wire by a compression 
screw, and sustaining the stump by pins, transfixing it oblicjuely. 
But pins and rubber ligatures are inferior to properly constrticted 
clamps, and Polk's vaginal hysterectomy clamps have given the 
writer good service. 





Fig. 210. — Porro operation: Highly flat- Fig. 211. — Porro operation: Highly 

tened pelvis, with paresis. flattened pelvis and obliquely contracted 

v,-ith hemiparesis. 

The value of the Porro operation has been iUustrated in the 
T\Titer's experience, where, in 20 infected cases delivered by abdomi- 
nal section, 12 have recoA^red. In these the Porro operation was 
performed, wliile in the others some other form of abdominal delivery 
was practised. In 1 case the patient, a primipara, had been sev- 
eral days in labor, and had been subjected by her attending physi- 
cian to rupture of the membranes, attempt at forceps dehvery, 



THE RESULTS OV DELIVKP.Y BY ABDo.MIXAL SECTION' 32/ 

attemptcil version, and attempted craniotomy with extraction. She 
was then brought on a raihvay train seventeen miles to the hospital. 
On opening the uterus its interior was green and gangi'enous, the 
odor so stinking as to affect the hospital staff who were present. 
Between one and two years after the Porro operation the patient 
had gained 30 pounds in weight, was in excellent health, without 
disability of any kin-l, and had permanently iDeen relieved of irri- 
tibility of the urinary bladder, which had been present since menstru- 
ation. 

THE RESULTS OF DELR^ERY BY -\BDOMINAL SECTION IN THE 
WRITER'S EXPERIENCE 

Up to the present time the writer has performed aMominal 
delivery by section in 95 cases. Of these. So have been done for 
pehic contraction or unusual fetal size, one or the other, or both, 
constituting dispropoition between mother and cliiL;l, as shown by 
failure of the presenting part to engage after the test of labor. Of 
these patients 72 were tminfected and in good general condition at 
the time of labor. Among these, 1 died, the cause of death being 
peritoneal infection by the Bacillus proteus ^i.ilgaris. The exact 
mode of infection could not be demonstrated, as the uterine incision 
was healed and sterile, and the suture material employed was found 
to be sterile. 

All of the children in these cases stirAdved the operation in good 
condition. 

20 cases were evidently infected at the time of laljor. and among 
these, 8 died and 12 recovered. Li those patients who recovered, 
the Porro operation was selected. Among the cliildren in these 
cases, 4 died from inspiration pneumonia and biith pressure, and 
6 were dea' 1 at the time of operation. 

Delivery by abdominal section was also practised for the follow- 
ing unusual conditions: 

Small multiple fibromata of the uterus, causing faihu'e of uterine 
contractions, in 1 case; presentation of the parietal bone, with pro- 



328 OPERATIVE OBSTETRICS 

lapse of the hand and arm, in 1 case; central placenta prsevia in 3 
cases; enlarged thyroid with previous loss of children from thyroid 
toxemia in difficult labor in 1 case; enlarged thyroid and contracted 
pelvis in 1 case; contracted pelvis and twin pregnancy, with failure 
of uterine contractions, in 1 case ; Cretan dwai'f with chronic toxemia 
in 1 case; tuberculosis of the hip- joint with malformed pelvis in 
1 case. These causes were operative in producing a fatal result 
with those mothers who died. Septic infection in 5 cases; toxemia 
of pregnancy, with toxemic gangrenous pneumonia, in 1 case; acute 
tubercular pneumonia from an old focus in the hip-joint in 1 case; 
occlusion of the intestine fourteen days after operation with chronic 
toxemia in 1 case; double pneumonia with Friedlander's bacillus 
in a patient infected before operation in 1 case. 

The mortality among the children resulted from polyhydranmios 
and monstrosity in 1 case; from prenatal hemorrhage from pre- 
mature birth in 1 case; from inspiration pneumonia in 4 cases. 

THE TREATMENT OF RUPTURE OF THE UTERUS 

Rupture of the uterus usually occurs transversely across the 
anterior wall through the lower uterine segment. It results from dis- 
proportion, usually accompanied by vigorous efforts on the part of 
the womb to expel its contents. It may happen when the fetus is 
impacted, as in shoulder presentation, or in what is apparently a 
perfectly normal spontaneous parturition. The accident is followed 
by the cessation of labor-pains, by great tenderness upon abdominal 
palpation, with a rigid condition of the uterine muscle, with shock, 
evidence sometimes of hemorrhage, and beginning septic infection. 
The indications are, in the presence of this accident, to remove the 
fetus and uterine contents and to repair the rent in the uterus, or 
to remove the womb. 

The Treatment of Uterine Rupture by Emptying the Womb and 
the Use of the Tampon. — Where the womb ruptures with the fetus in 
a favorable position for delivery, the rent not being large nor accom- 
panied by much hemorrhage or shock, the fetus may be cautiously 



THE TREAT.MEXT OF RUPTURE OF THE UTERUS 329 

extractcil, ami the patient treated by tamponing the uterus and 
inserting a tampon of 10 per cent, iodoform gauze through the lacera- 
tion in the uterine muscle. This tampon should be left forty-eight 
to se^'enty-t^vo hours and then removed. The vagina should be 
sponged out and not irrigated, and if the fingers of the op(>rator can 
pass readily thi'ough the laceration, the gauze packing should again 
be applied. A second one is usually sufficient. This form of treat- 
ment is especial!}^ valuable because it can be almost immediately 
applieil at the house of the patient, and comes ^itliin the scope of the 
general practitioner \^•ho has had some obstetric experience. Fur- 
thermore, statistics show that it is often not desiraV)le to transport 
such patients to hospitals, because the moA'ing adds to the shock 
under wliich the patient suffers and tends to produce a fatal issue. 

When, however, a considerable portion of the womb is torn, there 
will be evidence of this from the severity of the shock, evidence of 
hemorrhage, and the contour of the fetus will he more plainly felt 
through the abdominal wall. Fetal death occurs almost invariably 
in uterine rupture, so the life of the fetus need not be regarded in the 
treatment. 

I'nder these circumstances abdominal section should be performed. 
A"\ ith this the uterus should be completely emptied, the fetus and 
as much blood-clot as possible remoA'ed from the abdominal caAity. 
and the uterus carefully examined to determine the possibihty of 
retaining it. If the edges of the tear are clean, the tear of not A'ery 
gi'eat extent, the large vessels not torn across, the patient being in 
fairly good condition, the operator may bring together the torn edges 
with buried cat gait stitches, closing the peritoneal edges over with 
continuous catgut. The uterus shoidd be packed with gauze, which 
is carried out through the cervix into the vagina. Salt solution should 
be introduced within the alxlominal cavity an<l the abdomen closetl. 
Usually drainage is unnecessary: occasionally a gauze drain may be 
passed to the bottom of the pehdc cavity. 

Hysterectomy or total extirjiation of the uterus is. however, 
the safer operation when extensive laceration has occurred. Usually 



330 ' OPERATIVE OBSTETRICS 

supravaginal amputation in the form of celiohysterectomy, the 
tubes and ovaries being removed, is applicable in these cases. In 
infected patients, it may be better to perform complete extirpation 
of the uterus, draining the pelvic cavity with gauze. 

The Results of Treatment in Rupture of the Uterus. — This acci- 
dent is so serious that in many cases treatment is unavailing. Its 
success will depend upon the amount of hemorrhage wliich has 
occurred, the time wliich has elapsed before the patient is seen, and 
the prompt and skilful application of treatment. 

TOTAL EXTIRPATION OF THE PREGNANT WOMB 

The total extirpation of the pregnant womb is indicated for malig- 
nant disease, and may be selected where violent septic infection is 
present, the patient in fairly good condition. The blood-supply of 
the emptied uterus is controlled by hgation, the cervix separated from 
the vagina and bladder, and the womb entirely removed. Bleed- 
ing vessels are then ligated, and the flaps of peritoneal tissue are 
brought together, lea'vdng a gauze drain in the vagina if the case has 
been infected. In severe cases, with the patient in bad condition, it 
is best not to attempt to suture the broad ligaments or peritoneal 
surfaces, but to pack the pelvis with iodoform gauze, which may 
be gradually removed from the vagina. Extirpation of the uterus 
exposes the patient to greater risk of hemorrhage than hysterectomy, 
and it is not so readily accomphshed by an operator vrho has not had 
a large experience. 

Bibliography of Abdomixal Cesareax Sectiox" 

Adenot : Zentralblatt f. G^^nakologie. Xo. 48, 1907. 
Allen: American Journal of Obstetrics, Februaiy. 1909. 
Andrews: Transactions Obstetrical Society of London, vol. 4, 1906. 
Asch: Deutsche med. Wochens., p. 923, 1907. 
Ballika: Zentralblatt f. Gynakologie, Xo. 14, 1907. 
Banasc: Zentralblatt f. Gynakologie, Xo. 46, 1907. 
Bauer: ^lonatsschrift f. Geburtshiilfe und GA'nakologie, Band 24, Heft 
6, 1907. 



TOTAL EXTIRPATION OF THE PREGNANT WOMB 331 

Blancl-Sutton: Transactions of tlie Obstetrical Society of London, p. 

194, 1907. 
Bogdanovics: Zentralblatt f. Gynakologie, No. 12, 1909. 
Bonnaire: La Presse mod., p. 633, 1907. 
Boyd : American Journal of Obstetrics, August, 1909. 
Brindeau: L'Obstetrique, No. 1, Januaiy, 1909. 
Brink: Miinchener med. Wochens., No. 37, p. 1824, 1907. 
Brodliead : American Journal of Obstetrics, May, 1908. 
Buist: British Medical Journal, April 17, 1909. 

Cases by Russian Operators: Zentralblatt f. Gj^nakologie, No. 48, 1907. 
Couvelaire: Ann. de Gyn. et d'Obst., March, 1906. 
Cowen: British Medical Journal, January 26, 1907. 
Cramer: Deutsche med. Wochens., No. 51, 1907. 
Crowell: Annals of Gynecology and Pediatrics, p. 368, 1907. 
Das : Journal of Obstetrics and Gynecology of the British Empire, May, 

1908. 
Davis, A. B. : Bulletin of the Lying-in Hospital, New York, June, 1908. 
Davis, E. P. : Surgery, Gynecolog}^, and Obstetrics, November, 1906. 
Dirner: Zentralblatt f. Gynakologie, No. 14, 1907. 
Discussion, American Gynecological Society: American Journal of 

Obstetrics, June, 1909. 
Dobbert: Zentralblatt f. Gj^nakologie, No. 11, 1909. 
Doderlein: Miinchener med. Wochens., p. 963, 1907. 
Doleris: La Gyn., September, 1909. 
Endelmann: Zentralblatt f. Gj^nakologie, No. 11, 1908. 
Everke: Zentralblatt f. Gynakologie, No. 26, 1907. 
Fruinsholz and Michel: Ann. de Gyn. et d'Obstet., Januar}^, 1907. 
Fry: American Journal of the Medical Sciences, May, 1908. 
Fuchs: Zentralblatt f. Gynakologie, No. 6, 1909. 
Gallatia: Zentralblatt f. Gynakologie, No. 52, 1907. 
Griesel: Zentralblatt f. Gynakologie, No. 19, 1907. 
Grimsdale : Journal of Obstetrics and Gynecology of the British Empire, 

May, 1909. 
Gushee: Bulletin of the Lying-in Hospital, New York, No. 3, 1907. 
Hoeg: Hospitalstidende, p. 1217, 1907. 
Igelsrud: Zentralblatt f. Gynakologie, No. 4S, 1907. 
Jardine: British Medical Journal, September 19, 1908; Journal of 

Obstetrics and G^mecology of the British Empire, December, 

1908. 
Jardine, Zweifel, and others: British Medical Journal, September 19, 

1908. 
Jobestiansky : Jurn. akuscherstwa i shenskich bolesnei, November, 1907. 



332 OPERATIVE OBSTETRICS 

Kaiser: Charite-Annalen Jahrg., 2Sth, 1907. 

Kallmorgen: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 26, 
1907. 

Kayser: Zentralblatt f. Gynakologie, No. 48, 1907. 

Kolomenkin: Zentralblatt f. Gynakologie, No. 48, 1907. 

Kouwer: Zentralblatt f. Gynakologie, No. 46, 1907. 

Kiistner: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 63, Heft 
3, 1908; Monatsschrift f. Geburtshiilfe und Gynakologie, Band 
26, Heft 4, p. 606, 1907, and Band 28, Heft 3, 1908; Zentral- 
blatt f. Gynakologie, No. 44, 1907. 

Landon: Journal of Obstetrics and Gynecology of the British Empire, 
p. 273, 1907. 

Lemossu: Monatsschrift f. Geburtshiilfe und Gynakologie; Band 28, 
Heft 6, 1908. 

Leopold: Archiv f. Gynakologie, Band 81, Heft 3, 1907. 

Lepage: Zentralblatt f. Gynakologie, No. 19, 1907. 

Leumousse: These de Paris, January, 1908. 

Liepmann: Zentralblatt f. Gynakologie, No. 11, 1907. 

Lobenstine : American Journal of Obstetrics, October, 1908. 

Lumblach: Hygiea, p. 714, 1907. 

MacPherson: Bulletin of the Lying-in Hospital, New York, December, 
1908. 

Marbott: Annals of Gynecology and Pediatrics, p. 25, 1907. 

Markoe: Proceedings International Congress, Lisbon, April, 1906. 

Markoe and Davis: Annals of Gynecology and Pediatrics, p. 112, 1907.. 

Martin: Miinchener med. Wochens., No. 22, 1906. 

Mauschotta: La Presse med., p. 327, 1907. 

Meyer: L'Obstetrique, No. 1, February, 1908. 

Morse: Journal of the American Medical Association, No. 15, 1907. 

Muratow: Zentralblatt f. Gynakologie, No. 8, 1907. 

Newell: Surgery, Gynecology, and Obstetrics, May, 1909. 

Nijhoff: Nederl. tijdschr. v. Geneesk., Band 1, No. 21, 1907; Zentral- 
blatt. f. Gynakologie, No. 26, 1908. 

Oui: Rev. de Gyn., p. 529, 1907. 

Pinard: Rev. de Gyn., p. 531, 1907. 

Polak and Warren: American Journal of Obstetrics, October, 1908. 

Porter: Journal of American Medical Association, March 20, 1909. 

Potocki: Ann. de Gyn. d'Obst., June, 1906. 

Pottet: Bull, de la Soc. d'Obst. de Paris, No. 10, 1907. 

Proust and Pottet: Revue, de Gyn., p. 535, 1907. 

Reynolds: Surgery, Gynecology, and Obstetrics, March, 1907, and May,, 
1908. 



SI TKASYMPHYSEAL SECTION 333 

Rode: Norsk. Majazin for laegevidcnskaben, p. 13G1, 1907. 

Rodzewitz: Cliirurgie, Deceiiiber, 1907. 

Rotter: Zentralblatt f. Gynakologie, Xo. 49, 1908. 

Roiith: Journal of Obstetrics and Gynecology of the British Empire, 

p. 384, Xovember, 1907; January, Februaiy, 1911. 
Saks: Gazeta. Lekarska, Xo. 36, 1907. 
Scharpenack: Zentralbhitt f. Gynakologie, X'o. 23, 1907. 
Schauta: Zentralblatt f. Gynakologie, Xo. 14, 1908. 
Schmidt: Zentralblatt f. G3'nakologie, Xo. 25, 1908. 
Schneider: Miinchener med. Wochens., X'o. 41, 1907. 
Seuffert : Archiv f . Gynakologie, Band 82, 1907. 
Sieffart: Zentralblatt f. Gynakologie, Xo. 31, 1907. 
Sinclair: Journal of Obstetrics and Gynecology of the British Empire, 

X'ovember, 1907. 
Sippel: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 26, 1907. 
Spencer: Journal of Obstetrics and Gynecology of the British Empire, 

December, 1908. 
Stimono witch: Zentralblatt f. Gynakologie, X'o. 32, 1907. 
Studdiford: American Journal of Obstetrics, September, 1909. 
Yallenta: Zentralblatt f. Gynakologie, Xo. 52, 1907. 
Veit : Monatsschrift f . Geburtshiilfe und Gynakologie^ Band 26. Heft 1, 

1907. 
von Franque : ^lonatsschrift f . Geburtshiilfe und Gynakologie, Band 63, 

Heft 1, 1908. 
von Guerard : Monatsschrift f . Geburtshiilfe und Gynakologie, Band 25, 

p. 417, 1907. 
Voren and Tixier: Lyon med., March 31, 1907; Zentralblatt f. Gyna- 
kologie, Xo. 26, 1908. 
Wallace : Journal of Obstetrics and Gynecology of the British Empire, 

December, 1907. 
Warren and Polak: American Journal of Obstetrics. October, 1908. 
Wechsberg: "Wiener klin. AVochens., 1906. 
Weisswange: Zentralblatt f. Gynakologie, X'o. 8, 1908. 
Wrazidlo: Inaug.-Diss., Leipzig, 1906. 
Wyder: Archiv f. G^'nakologie, Band 82, 1907. 
Zacharias: Med. Klinik, Band 3, p. 82, 1907. 

SUPRASYMPHYSEAL SECTION 

The proposition to open the uterus above the pubis without open- 
ing the peritoneal sac is b}^ no means recent. Among others who 
suggested this was Physick, quoted by Dewees in a System of ]\Iid- 



334 OPERATIVE OBSTETRICS 

wifery, Philadelphia, 1826. Physick, Dewees, and Horner, in dis- 
cussing the matter, believed that such an operation was possible, 
and proposed to make a horizontal section in the muscles of the ab- 
dominal wall above the pubis, separating the peritoneum from the 
bladder and incising the cervix and lower uterine segment. This 
operation has been recently revived by Frank, Latzko, and Sellheim, 
and by the latter is considered especially applicable to infected cases. 
The Technic of the Operation. — The patient is prepared as usual for 
abdominal section, the shoulders are depressed and the pelvis consid- 
erably raised ; the Trendelenburg posture with moderate elevation is 
required. PfannenstieFs transverse abdominal incision is then made, 
extending broadly across the lower abdomen several inches above 
the pubes. The recti muscles are divided transversely several inches 
from their attachment. With the fingers covered with gloves or gauze, 
or with both, the operator works his way downward into the con- 
nective tissue in front of the abdominal peritoneum, pushes the 
bladder upward and forward over the pubes, and the peritoneal sac 
upward toward the diaphragm. The lower uterine segment contain- 
ing the presenting part is then exposed. The uterus is opened longi- 
tudinally and, if possible, the fetus expelled by abdominal pressure. 
When this fails, the forceps or version may be employed. The 
placenta is expressed when the uterus is emptied, and the uterus 
tamponed with iodoform gauze, which is carried through the cervix. 
The uterine incision is then closed with continuous catgut and the peri- 
toneal and muscular incisions are closed in Hke manner. Before 
the child is extracted the patient is lowered from the Trendelenburg 
posture to the horizontal position, as hemorrhage seems to be less 
frequent in this posture. If the uterus is infected, Sellheim's method 
of causing a permanent uterine fistula may be followed. This con- 
sists in uniting the edges of the wound in the abdomen with the edges 
of the uterine incision ; the uterus is packed with gauze, which is brought 
out through the fistula thus made. This gauze is renewed during the 
puerperal period until the infection has subsided. The fistula is 
then allowed to close. 



SUPRASYMPHYSEAL SECTION 335 

The Advantages of the Suprasymphyseal Method. — It b claimed 
by those who urge tins muthotl that it avoitls the •dangers of opening 
the peritoneal ca\'ity^ that it is attemlecl with little hemorrhage and 
shock, that the child is si^eeilily delivered, and in septic cases that it 
retains the uterus, while eflficiently treating the septic condition. It 
leaves the patient usually with the uterus anteverted, sometimes 
slightly adherent to the abdominal wall, and the pehic organs in good 
general condition. 

The Disadvantages of the Suprasymphyseal Method. — ^The dis- 
advantages consist in the liabiUty of woim«:ling the i)eritoneimi, while 
the space available for deUvery is often not sufficient for the passage 
of the child without severe stretching and tearing of the soft tissues. 
If an opening through the peritoneum occiu^, it should be immediately 
closed by continuous catgut stitch. But even if this be promptly 
done, septic infection may have entered. The emptying of the uterus 
by this method is sometimes followed by shock and sudden hemor- 
rhage, re<:itiiring the application of the gauze tampon to control it. 
Although the danger of wounding the bladder is not great, it is not 
entirely absent, and such an accident has happened. Some urge that 
the bladder be completely emptied before the operation, while others 
assert that this con«lition makes but little difference. 

The Results of Suprasymphyseal Section. — Zweifel. in a paper 
read before the British Metlical Association in 1908, reported 4 
extraperitoneal hysterotomies with recoveries. One patient had 
fever before and after the operation, but recovered after the bmsting 
of an abscess. He urges transverse incision, beUeving that it leaves 
a much stronger scar. The fact that Zweifel has performed 16 sub- 
cutaneous symphysiotomies with no maternal death, 52 open s^tu- 
physiotomies with 3 deaths, 13 cehohysterotomies with a total death- 
rate in these operations for the mother of 5.3 per cent., makes his 
report of value in estimating the advantages of the operation. 

Sellheim^ prefers anesthesia with scopolamin-moqjhin. The 
pehis is sUghtly raised, a transverse incision 15 to 20 cm. \6 to 8 
^ Zentralblatt f. Gynakologie, Xo. 5, 1908. 



336 OPERATIVE OBSTETRICS 

inches) long is carried down to the fascia, and hemorrhage is com- 
pletely checked by ligating the small vessels. The fascia is incised 
transversely, the flaps closed by stitches, and the recti muscles sep- 
arated longitudinal^. The peritoneal and subperitoneal tissue is 
then separated from the inferior surface of the recti muscles. To 
outline the bladder it is moderately distended with sterile salt solu- 
tion. With blunt scissors and pledgets of gauze the operator sep- 
arates the peritoneum from the bladder to the cervix. With the 
bladder pushed downward as far as possible, the cervix is opened in 
the median hne, the incision carried upward into the uterus, and 
the child pressed downward and delivered. After removing the child 
the uterus is urged to contract spontaneously, bringing the placenta 
into the wound. It is then delivered, and the uterus and cervix 
tamponed with gauze. 

After closing the incision with continuous catgut the pelvis is 
lowered, the bladder replaced, and a few buried catgut stitches used 
to restore the fascia to its usual position. The patient is kept as quiet 
as possible for a short time after the operation. The average time 
of operation is about forty minutes. 

In Sellheim's experience, streptococcus infection of the entire 
wound occurred in 1 case, proving fatal. In 1 case abdominal 
Cesarean section had been once performed and the extraperitoneal 
section also proceeded successfully. 

The reports of various operators show that, if necessary, version 
may be done through the uterine incision and the child thus deliv- 
ered. 

The Application of this Method to Septic Cases. — In cases where 
embryotomy is impossible by reason of the contracted condition of 
the pelvis, the effort has been made by Sellheim and others to deliver 
the fetus and retain the uterus by establishing drainage through a 
utero-abdominal fistula. The delivery of the child is effected in 
the manner described, and after the uterus is empty the edges of the 
uterine incision are united to the edges of the abdominal incision. 
The peritoneum is carefully examined for traces of injury, and if such 



SUPKASYMPHYSEAL SECTION 337 

has occurred, it is immediately repaired with fine catgut. The uterus 
is tamponed with iodoform gauze, a portion of which is carried through 
the cervix if sufficient dilation be present. If not, the cervix is 
moderately dilated with solid dilators. The remainder of the gauze 
from the uterine cavity is brought out through the abdominal incision, 
thus establishing external abdominal drainage. The fistula is allowed 
to close gradually as the patient's temperature falls and conva- 
lescence is estabUshed. 

' Reifferscheid^ reports 19 cases of suprasymphyseal or extraperi- 
toneal section. The best results were obtained by using the Pfan- 
nenstiel transverse incision. Little attention was paid to the con- 
dition of the bladder, although usually it was thought best to inject 
from 100 to 150 cm. of sterile salt solution. If the bladder is dis- 
tended it encroaches upon the field of operation, and if it is entirely 
empty it is diflScult to find its edge. It is best to open the uterus 
by a longitudinal incision, as hemorrhage is less and a firmer scar 
is secured. Severe hemorrhage was found in but 1 of these cases, 
and to avoid this it is best to take ample time for the delivery of 
the placenta. It is important, after delivering the child, to place 
the patient in a horizontal position. Hemorrhage from the uterus 
is thus observed more readily and prevented. Ergot was adminis- 
tered to secure uterine contraction, and adrenalin was tried, but not 
found successful. In some cases it was necessary to tampon the 
uterus. In 1 case the uterus was inverted through the incision, but 
without serious result. 

Of the 19 cases, 16 were operated upon for contracted pelvis. 
The results were so good that the suggestion was made that intra- 
peritoneal Cesarean section ma}' in future be limited to cases where 
a uterine tumor or other abdominal tumor is present as a complica- 
tion, or where it is desired to render the patient sterile. In 1 case 
of placenta prsevia the operation proved satisfactory; although the 
vessels in the lower uterine segment were well developed, and the 
placenta lay beneath the incision^ there was no severe hemorrhage. 

1 Zentralblatt f. Gynakolgie, No. 33, 1909. 
22 



338 OPERATIVE OBSTETRICS 

After the removal of the placenta the uterus was thoroughly tam- 
poned. The child became so anemic from loss of blood that it lived 
but a few hours. It was observed that the lower uterine segment 
was variously distended in these cases. Evidently the operation 
could be done before the patient had labor-pains, although it is more 
easily accomplished when the lower uterine segment is greatly 
stretched. Good results were obtained in cases not aseptic at the time 
of operation. In one patient suppuration in the wound occurred 
which did not prove serious. Should infection evidently be present, it 
would be well to pass a gauze drain from the uterus into the anterior 
vaginal vault, closing the upper wounds completely. Jahreiss,^ 
Nacke,^ Heinricius,^ Eversmann,* Frank,^ and Rubeska all report 
successful cases. 

Latzko ^ gives priority to Jorg in 1806. Ritgen, in 1821, modi- 
fied the original proposal, and Latzko recognizes Physick's proposed 
operation in 1824 as practical^ the modern operation of Sellheim. 
Thomas, in 1870, performed laparo-elytrotomy. 

At present three methods are proposed for this operation: A 
transverse incision, which consists in incising the peritoneum trans- 
versely, stitching the flaps, and extracting the child, Frank's method; 
the extraperitoneal, by dissecting the bladder from its peritoneal 
connection; Sellheim's method, or Latzko's method, which consists 
in pushing aside the bladder from the uterus and opening the uterus 
longitudinally. The principal danger of the method consists in the 
possible infection of the connective tissue, and in wounds and injuries 
to the lower uterine segment. 

Latzko collected 150 cases, with a general mortality of 7.3 per cent. 
The maternal mortality from infection was 5.4 per cent.; the fetal 
mortality was nil. 

Jeanin^ collected 148 cases from the literature of the subject. 
He illustrates his paper by drawings, showing the various steps of the 

1 Zentralblatt f. Gynakologie, No. 33, 1909. ^ i^id. 

^ Ibid. 4 Ibid. 5 Ibid. 

^Wiener klin. Wochenschrift, No. 14, 1909. 
' L'Obstetrique, No. 8, 1909. 



SUPHASYMI'HYSIOAL SECTION 339 

operation. There were in the 148 cases, 8 maternal (heaths from in- 
fection, 2 from eclampsia, and 1 from several causes. The mat(^rnal 
mortality was 7.45 per cent. The percentage of deaths from infectioa 
was 3.04 per cent. 

His paper covers 42 cases not included in Latzko's table, which 
gives a collection in all of 190 cases, with a maternal mortality of 
7.37 per cent, from all causes, and a maternal mortality by infection of 
4.21 per cent. At present it may be asserted that the mortality of 
the operation will range from infection only between 4 and 5 per cent. 

The morbidity shown by these statistics is a high one — 30.7 per cent., 
of which 25 per cent, occurred from infection, and the remainder 
from various causes. It is notable that in some of these cases the 
bladder was involved. 

As regards the fetus, asphyxia was seen not infrequently, and the 
fetal mortality was estimated from all causes at 3.62 per cent. There 
seems to be no choice between the transperitoneal and extraperitoneal 
methods of performing the operation. 

Lewis ^ reviews the literature, collecting 102 cases, with 9 maternal 
deaths, and 5 fetal deaths, with a maternal mortality of 8.8 per cent.^ 
and a fetal mortality of 8.6 per cent. 

In uninfected cases it cannot as yet be proved that suprasymphyseal 
Cesarean section, with or without opening the peritoneal cavity, but 
opening the lower uterine segment, gives as good results as celiohys- 
terotomy where the uterus is removed from the abdominal cavity and 
the incision made through the contractile portion of the womb. In 
suprasymphyseal section the portion of the womb selected for incision 
is rich in blood-vessels, easily torn, and often lies at some depth in 
the abdomen and is difficult of access. It has yet to be demonstrated 
that this method is superior in uninfected cases. 

Its originators proposed it as a substitute for the Porro operation 
in infected cases, hoping thus to save the uterus. Its claim to accept- 
ance upon this ground has yet to be established, although its advan- 
tages in suitable cases, where the condition of the tissues is such as to 

^ American Journal of Obstetrics, October, 1909. 



340 OPERATIVE OBSTETRICS 

render its performance comparatively easy, cannot be denied. So 
much can be done, however, by embryotomy in infected cases, drain- 
ing the uterus afterward by gauze packing through the vagina, that 
the operator must be sure of his ground before abandoning this pro- 
cedure for suprasymphyseal section. One cannot readily see its ad- 
vantages in placenta prsevia, where the placenta must inevitably be 
wounded during the opening of the uterus from its low attachment at 
the site of the uterine incision. Further experience is necessary 
before the exact value of the operation can be proved. 

Bibliography of Suprasymphyseal Section. 

Baumm: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 27, 
Heft 2, 1908. 

Czj^zewicz : Zentralblatt f . Gynakologie, No. 25, 1908. 

Discussion: Zentralblatt f. Gynakologie, No. 29, 1909; Monatsschrift f. 
Geburtshiilfe und Gynakologie, June, 1909. 

Doderlein: Zentralblatt f. Gynakologie, No. 4, 1909; Monatsschrift f. 
Geburtshiilfe und Gynakologie, Band 29, Heft 6, 1909; Miinchener 
m. Wochenschrift, No. 32, 1909; La Presse med., No. 83, 1909. 

Diihrssen: Berliner klin. Wochenschrift, No. 5, 1909. 

Fraipont: L'Obstetrique, July, 1909. 

Frank: Archiv f. Gynakologie, Band 81, 1907; Monatsschrift f. Geburts- 
hiilfe und Gynakologie, Band 75, 1907; Proceedings, 16th Inter- 
national Congress, Budapest, 1909. 

Franz : Zentralblatt f . Gynakologie, No. 24, 1909. 

Freund: Zentralblatt f. Gj^nakologie, No. 16, 1909. 

Fromme: Zentralblatt f. Gynakologie, No. 17, 1908. 

Fuchs: Zentralblatt f. Gynakologie, No. 21, 1909. 

Hammerschlag : Zentralblatt f. Gynakologie, No. 50, 1908. 

Holzapfel: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 63, Heft 
2, 1908. 

Hermann: Versamml. deutsche Naturf. in Salzburg, No. 81, 1909. 

Jahreiss: Zentralblatt f. Gynakologie, No. 7, 1909. 

Jeannin: L'Obstetrique, No. 8, 1909. 

Kahn: Zentralblatt f. Gynakologie, No. 50, 1908. 

Kehrer: Beitr. z. Geb. u. Gyn., Band 14, 1909. 

Kermauner: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 29, 
1909. 

Kramer: Journal of Obstetrics and Gynecology of the British Empire, 
December, 1908. 



EXTHArKHITOXEAL SECTION BY INGUINAL INCISION 341 

Kroemer: Miiiu'lioner med. Wocliens., Xo. 42, 1908. 

Kiistner: Zentralblatt f. Gynakologic, Xo. 16, 1908; Miinchcner med. 
Woc'henschrift, Xo. 34, 1909; Monatsschrift f. Geburtshiilfe und 
Gynakologie, Band 29, 1909. 

Latzko: Zentralblatt f. Gynakologie, X'os. 8 and 22, 1909; Monats- 
schrift f. Gebuilshiilfe und Gynakologie, Bands 29 und 30, 1909; 
Wiener klin. Wochenschrift. 1909. 

Lewis: American Journal of Obstetrics, October, 1909. 

Luchsinger: Zentralblatt f. Gynakologie, X^o. 33, 1908. 

Xiirnberger: Zentralblatt f. Gynakologie, X'o. 26, 1909. 

Olshausen: Zentralblatt f. Gynakologie, Xo. 43, 1909. 

Pfannenstiel and others: Zentralblatt f. Gynakologie, X'o. 25, 1909. 

Puppel: Monatsschrift f. Geburtshiilfe und Gynakologie. Band 29, Heft 
3, 1909. 

Reifferscheiclt : Monatsschrift f. Geburtsludfe und Gynakologie, Band 
30, 1909; Zentralblatt f. Gynakologie, Xo. 33, 1909. 

Rubeska: Zentralblatt f. Gynakologie, Xo. 33, 1909. 

Runge: Archiv f. Gynakologie, Band 89, 1909. 

Schauta: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 29, 
1909. 

Scheffzek: Deutsche m. Wochenschrift, Xo. 32, 1909. 

Sellheim: Zentralblatt f. Gynakologie, X'os. 5 and 10, 1908; Beitrage 
z. Geb. u. Gyn., Bands 13 imd 14, 1909; Zentralblatt f. Gyna- 
kologie. X'o. 37, 1909; Berliner klin. AYochenschrift, Band 30, 
1909; Gyn. Rundschau, Heft 16, 1909. 

Sellheim and Frank: Monatsschrift f. Geburtshiilfe und Gynakologie, 
Band 28, Heft 5, 1908. 

Thorn: Proceedings, Gemian Gynecological Society, June 27, 1909; 
Gyn. Rundschau, Xo. 8, 1909. 

UthmoUer: Zentralblatt f. Gj^nakologie, X'o. 45, 1908. 

Veit: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 26. 1907, 
and Band 28, Heft 5, 1908; Miinchener med. Wochens., p. 1610, 
1907. 

vonFranque: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 63, 
Heft 1, 190S. 

Wiemer: Zentralblatt f. Gynakologie, Xo. 39, 1908. 

EXTRAPERITONEAL SECTION BY INGUINAL INCISION 

Extraperitoneal section was described and practised, and re})eated 
efforts have been made to empty the uterus without opening the peri- 
toneum by incision through the Iowtp lateral portion of the abdominal 



342 OPERATIVE OBSTETRICS 

wall, pushing up the peritoneal sac and incising the uterus through 
the cervix and vaginal junction. 

In October, 1821, Ritgen operated by this method, with an unsuc- 
cessful result, probabty produced by the application of poultices 
which brought about fatal postpartum hemorrhage. Physick and 
Horner, in 1825, made anatomic studies in this direction, which 
were never put into actual operation upon the living. In 1870 
Thomas advocated operation by liis method, which consisted in dilat- 
ing the cervix with the hand, carrying the incision from the symphysis 
to the right anterior superior spine and dowmward to the peritoneum, 
which was separated and pushed upw^ard. He then exposed the cer- 
vix and vagina and cut through the vaginal wall upon a sound intro- 
duced into the vagina and maintained in place by an assistant. The 
cervix was drawn through this w^ound into the external wound and 
by a blunt tractor or hook the fetus was then extracted. His first 
case was one of eclampsia terminating fatally for mother and child 
soon after operation. 

He then operated successful^ upon a young primipara with a 
highly contracted pelvis. 

Skene, in 1876, reported 2 successful cases. In 1878 the Amer- 
ican Gynecological Society pronounced the operation feasible, and it 
was designated '^aparo-elj^rotomy." In his monogi'aph upon the 
history of extraperitoneal section, Niirnberger (Zur Geschichte des 
extraperitonealen Kaiserschnittes, Inaug. Diss., Miinchen, 1909) 
states that fourteen of these operations were reported by the follow- 
ing authors: Thomas, 2; Skene, 5; Gillette, 1; Hime, 1; Edis, 1; 
Duncan, 2; Jewett, 2 — 14 in all. 

Of these, 7 mothers recovered and 7 died. 

It is stated that the mortality of the children was 42 per cent., 
and that the bladder was wounded in 6 cases. 

If these cases are critically analyzed, it is found that many of them 
were in a condition unfavorable for any major operation. The true 
mortality of the operation was not a high one. 

In Ritgen's claim for priority, the name of Jorg must not be 



EXTKAPEKITONEAL SECTION BY INdUINAL INCISION 343 

omitted, as Jorg proposed and devised the operation first, which 
Ritgen afterward performed. 

Ill 1881 Frank tried to improve upon Thomas' methcjd by sutur- 
ing the round ligaments to the abdominal wall, forming a tent of peri- 
toneum to shut off the lower portion of the uterus from th(^ abdominal 
cavity, and making the incision in the uterus as low as possible. This 
method proved too complicated for general use. 

In 1907 Frank devised an operation by transverse incision above 
the pubis, opening the peritoneal cavity, detaching and stitching the 
vesico-uterine fold to the parietal peritoneum, incising the uterus 
transversely, and, if possible, allowing the fetus to be delivered spon- 
taneously through the channel thus formed. In clean cases the 
wound was closed by catgut after the uterus had been emptied. In 
suspected cases the uterus was left open and drained by iodoform 
gauze passed through the vagina. 

Frank had 13 cases, with no death. This method was then some- 
what modified, and employed by Fromme and Veit. Following 
somewhat Frank's original plan, Sellheim and Latzko devised the 
methods which have recently been extensively employed. 

Doderlein (Monatsschrift f. Gerburtshtilfe und Gynakologie, Band 
33, Heft 1, 1911) has devised an operation which he has practised in 
32 cases, which is essentially as follows: The patient is placed in 
practically the Trendelenburg posture and an incision made in the 
inguinal region along Poupart's ligament from the anterior superior 
spine to the symphysis. His operations have been performed upon 
the right side, but he sees no essential reason why the left side may not 
be chosen. Some of his earlier operations were begun by the Pfan- 
nenstiel transverse suprapubic incision, but he afterward abandoned 
that for the superficial and deep inguinal incision. The skin, super- 
ficial fascia, and external and internal oblique muscles are separated. 
it being found necessary to wound the muscular tissue but very little. 
It is not necessary to cut the rectus muscle. Should it be excessively 
wide, it can be pushed to one side. The lower border of the trans- 
versalis must often be separated. The epigastric vessels are then 



344 



OPERATIVE OBSTETRICS 



exposed and are divided between double ligatures. The connective 
tissue is then separated readily by the finger, and access gained to the 
inferior portion of the uterus, and the parametrium exposed below 



i 






Fig. 212. — Position of the patient and incision for extraperitoneal lateral 
Cesarean section. The patient is placed with the pelvis raised as high as possi- 
ble, and incision is made in the inguinal region, on the right or left side (Doderlein) . 

the peritoneum. In the middle line the lateral border of the urinary 
bladder is seen, and on the external aspect of the wound are the large 
vessels. The round ligament is visible, and in one case it was divided 



EXTRAPERITONEAL SECTION BY INGUINAL INCISION 



345 



between ligatures. It is usually possible to draw it aside. The ureter 
is not in the field of operation, and with ordinary care it should 
not be wound al. The peritoneum can be pushed out of the way, it 
is thought, far more easily in the lateral than in the median operation. 
In the former the peritoneum is so high that it does not present in 
the field of operation. The uterine wall is then severed from one 
to two fingers' breadth from the right lateral border of the urinary 
bladder and parallel with the edge of the bladder. The uterus is 



A. n. V. 
epigrastrica 



Symphysis 
pubis 



M. 
obi. int. 



-M. 

obl.cxt. 




Peritoneal tolO 



Uterus 



Fig. 213. — Anatomy of the tissues at the line of incision. The vessel cross- 
ing the wound is the epigastric vein. The urinary bladder is seen in the median 
line, and above it the lower uterine segment (Doderlein). 



usually distended by the head, and it is not necessary to operate dur- 
ing uterine contractions to come readily upon the presenting part. 
The uterine wall at this point is found unusually thin and distended . 
The scalp of the child is also readily seen. In some cases with vessels 
of considerable size, apparently a large vein has occasioned some 
hemorrhage and has required ligation. In one case only did profuse 
hemorrhage occur. In this patient it was impossible to enlarge the 
wound sufficiently to deliver the child, and the wound was packed with 



346 



OPERATIVE OBSTETRICS 



compresses, the abdomen opened, and the usual Cesarean section 
performed. Bleeding ceased when the uterus was emptied, and the 
patient made a good recovery. The bleeding was thought to come 
from varicose veins in the parametric tissue. 

The child is delivered through the incision by forceps, the pelvis 
being lowered for the application. Care must be taken in delivery 
not to tear the uterus, and when the amniotic liquid has not escaped, 
the membranes may be ruptured and version immediately performed. 



Bladder 



Symphysis 
pubis 




Peritoneal fold 



Fig. 214. — Opening the uterus parallel to the lateral border of the urinary bladder, 
the head of the child appearing in the wound (Doderlein) . 



If the child be large and extraction difficult, the wound may tear up- 
ward and the peritoneum be injured. This is not serious and can 
readily be repaired by suture. In no case did blood or amniotic liquid 
enter the peritoneal cavity. 

After the delivery of the child, the pelvis of the patient is again 
raised, the placenta delivered, and the uterine cavity tamponed with 
gauze, which is carried through the cervix into the vagina. The 
edges of the wound are then seized with clamps and drawn upward, 



extuapp:kitonkal sp^ction by inguinal incision 



347 




Fig. 215. — Delivery of the child by forceps after the uterus is opened. The 
patient is placed with the pelvis lowered (Doderlein). 

Bladder 




Uterus 



Fig. 216.— Closing the uterine incision with continuous catgut stitch. The edges 
of the wound are pulled strongly upward by the forceps (Doderlein) . 

and the wound thoroughly inspected and the bleeding points, if 
necessary, ligated. Should the cervix not be sufficiently opened, it can 



348 OPEKATIVE OBSTETRICS 

readily be drawn upward and dilated or incised before or after the ex- 
traction of the child. 

There is, however, no good reason for extensively opening the cer- 
vix, as only sufficient room for drainage is required. The uterine 
wound is then closed with continuous catgut in two layers, the super- 
ficial layer bringing together the connective tissue, and a strand of 
iodoform gauze is used to drain the connective tissue. The skin and 
fascia are united in the usual manner. 




Fig. 217. — The wound in the uterus completely closed and the connective tissue 
between the bladder and uterus stitched over the uterine wound (Doderlein). 

The suture of the uterus and connective tissue is so applied that 
the upper layer of sutures closes the connective tissue above the 
bladder over the greater portion of the uterine wound. 

In Doderlein's 32 cases, 3 mothers and 2 children died ; one mother 
died of eclampsia twelve hours after operation; the second had been 
four days in labor, and repeatedly examined, and the membranes had 
ruptured thirty-four hours before operation. There was a foul dis- 
charge from the uterus, and the patient had fever. The pelvis was 
highly contracted, and the child living. The mother died eight days 
after operation from septic infection, with suppuration in the con- 
nective tissue and gangrene of the bladder. The child had inspired 



RUPTURE OF THE UTERUS 349 

septic material and could not be resuscitated. The third mother died 
from paralysis of the intestine on the fourth day after oix^ration. 
On section, no infection could be found, and no cause for the ileus. 

In addition to the two children which could not be resuscitated, 
two died during the first week of life; 28 left the hospital in good 
condition. 

Dodexlein believes that this operation is technically more difficult 
than intraperitoneal section. The delivery of the child is not so easy 
as by intraperitoneal oi^eration, and the mother's convalescence Is 
more complicatetl. 

Doderlein quotes 53 cases of helx>stiotomyj with one maternal death 
from paralysis of the intestine. 

Autopsy showed no injmy to the abdominal tissues. In 321 
cases of hebosteotomy recently reported he finds a maternal mortality 
of l.S per cent. He would reserve hebosteotomy for multipaKe with 
contracted pelves of the first and second grades. He would not per- 
form this operation when the true conjugate was less than 7 cm. 

Rupture of the Uterus 

This serious accident complicating parturition reciuires siu^cal 
attention for the rescue of the mother. 

Etiology. — Rupture of the uterus occurs In patients in whom the 
generative tract is but partially developed, in whom the uterine 
muscle has been weakened by relocated pregnancy and altered by 
infection or other disease, in patients having contracted i>elves, in 
cases where an impossible presentation develops, and in patients 
in whom the uterus has been altered by some previous operation. 
The uterus may also be ruptiu-ed by imskilful and improper attempts 
at delivery, and is repeatedly torn into the pelvic or peritoneal cavi- 
ties by unskilful rapid dilation. 

Varieties of Rupture. — Most often the rupture is trans\'erse on 
the anterior or posterior surface across the lower uterine segment. 
Less frequently it is oblique and ragged in outline. In lacerations 
or rupture complicating attempts at delivery, the tear extends 



350 



OPERATIVE OBSTETRICS 



obliquely at the sides of the uterus, or may perforate the wall of the 
womb on the posterior aspect or at the fundus. 

Signs and Symptoms. — The signs and symptoms of uterine rupture 
are, cessation of labor-pains, hemorrhage, vaginal or concealed, shock, 
often attended with severe abdominal pain, the death of the fetus,. 




Fig. 218. — Laceration of the lower part of the uterus and the vaginal vault. 
The uterus is turned over to the right to show the laceration (Kerr). 

abnormal contour of the uterus, with the recognition of the fetus lying 
wholly or partially in the abdominal cavity. 

The Natural History of Uterine Rupture. — In neglected cases the 
death of the fetus is accompanied by the escape of amniotic liquid 
into the abdominal cavity and the extravasation of blood, followed 
by the development of peritonitis. Infection speedily follows, and 



RlTTrUE OF THI-] ITKUUS 



351 



if the patient does not die from hemorrhage and shock, she perishes 
from sepsis. In cases of slight rupture within th(^ womb recovery 
may follow, but such is the rare exce]^tion and not the rule. 




Fig. 219. — Rupture of the uterus. Fetus lying in the abdominal cavity: a, 
The anterior abdominal wall rejfleeted; b, omentum; c, anterior surface of the uterus; 
d, the edge of the rent in the uterus. (A. Lionel Smith in Journal of Obstetrics and 
Gynecology of the British Empire.) 



The Symptoms of Threatened Uterine Rupture. — Failure of the 
fetus to engage and descend into the pelvis, with excessively strong 
uterine contractions, excessive distention of the lower uterine seg- 
ment, with distinct formation of a contraction-ring, and its gradual 
ascent, portend uterine rupture. It must be remembered, however, 



352 



OPERATIVE OBSTETRICS 



that the accident may happen during spontaneous labor, in which 
the child has descended into the pelvic cavity and is about to be 
expelled, or has been spontaneously born. 

The Prevention of Uterine Rupture. — The recognition of contracted 
pelvis, with measures suitable to deliver the patient in the most ad- 




Fig. 220. — Photograph of uterus which ruptured spontaneously during labor: 

I, Fundus drawn toward right; 2, 3, origin of right and left round ligaments; 4, 
infundibulopelvic ligament; 5, 6, right and left tube; 7, peritoneum separated from 
anterior uterine wall; 8, 9, peritoneum separated from uterus; 10, strip of cervix; 

II, edge of rupture; 12, edge of incision; **, attachment to peritoneum; line 1, 
axis of uterine muscle; line a-b, axis of pelvic brim. (Sitzenfrey.) 

vantageous way, are especially important in preventing rupture of 
the uterus. When the conditions are favorable for vaginal delivery 
the prompt removal of the child prevents uterine rupture. The 
correction of unfavorable presentation, the precaution to empty the 



RlTTrUE OF THE ITKIUS 353 

bladder of the patient sufficiently often, and to sustain her general 
strength, are also valuable aids in })re venting the accident. Such 
measures as tend to bring the fetus favorably and promptly into the 
pelvic cavity will assist in avoiding uterine rupture. 

The Treatment of the Accident. — Two methods of treatment are 
available in this comphcation, and the choice between them will depend 
upon the nature and extent of the rupture, the skill of the operator, 
and the circumstances in wliich the patient is placed. 

AVhen the head of the fetus is presenting and remains within the 
pelvic brim or pelvic cavity, rupture of the uterus is rarely so extensive 
as when the head escapes from the womb. The retention of the pla- 
centa within the uterus renders the accident less formidable. Under 
these conditions the obstetrician must empty the womb as speedily 
as possible, and then examine thoroughly, to determine the site, extent, 
and nature of the rupture. In such cases it is usualh' partial, not 
attended with great hemorrhage or shock, and may often be success- 
fully treated without abdominal section. It must be taken for granted 
that some of the uterine contents have escaped into the siUTOimding 
tissues through the point of rupture. 

To guard against infection drainage must be instituted, and this 
may be done by tamponing the womb with 10 per cent, iodoform 
gauze, and passing a strand of this gauze through the rupture in the 
uterine waU and into the surrounding tissues. If tonic doses of strych- 
nin and ergot be given, and the uterus kept firmly contracted, the 
patient will often recover without further treatment. There is, how- 
ever, risk of the development of infection, and the method is not 
as reliable as abdominal section, with inspection of the uterus and 
such other operative treatment as may be indicated. 

AVhether the obstetrician will treat the accident by tampon and 
drainage will depend not only upon the extent of the rupture, but upon 
the circumstances under which it occurs. If the patient is exhausted 
and somewhat shocked and cannot readily be taken to a hospital, and 
the operator must treat the case in her dwelling, it may be best to 
proceed with the tampon and gauze drainage. Such can be appUed 

23 



354 OPERATIVE OBSTETRICS 

with limited assistance, and with such aseptic technic as can be com- 
manded in the ordinary dwelling. 

If, however, the patient be in fair condition, a suitable hospital 
easily accessible, and the patient readily consents to operative 
treatment, she will do best to be transported to a hospital and sub- 
jected to operation. 

Where the laceration is extensive, and a considerable part of the 
fetal body escapes into the pelvic or abdominal cavity, abdominal 
section offers the only chance for recovery. Delay increases the 
danger very greatly, and no time must be lost in transporting the 
patient to the hospital. Abdominal section should be done as soon 
as possible, and the operator prepared to close the rent into the 
uterus, or to perform hysterectomy, partial or total. 

In preparing for operation, the patient should be made ready 
for intravenous saline transfusion, and appliances for stimulation 
should be at hand. She should be catheterized under ether, and 
the character of the urine noted. If it is bloody, it is possible that 
the bladder has been injured; and if no urine be obtained by cathe- 
ter it is possible that the bladder has been torn sufficiently to per- 
mit the urine to escape into the pelvis or abdomen. In operating 
the obstetrician may require the Trendelenburg posture to examine 
thoroughly the tissues in the deeper portion of the pelvis. 

The abdomen should be opened in the median line with a sufficient 
incision to permit the easy removal of the child, and give free access 
to the field of operation. The fetus should be removed as carefully 
as possible, so as not to increase the laceration or set up fresh hemor- 
rhage. The cord should then be followed to the placenta, and if this 
is not entirely separated, it should be removed from the wall of the 
uterus and delivered. In extensive lacerations the placenta usually 
separates and is sometimes found in the abdominal cavity. The 
pelvis should be sponged with sterile sponges, and the extravasated 
blood and amniotic liquid removed as far as possible. 

In cases of transverse rupture of the uterus an attempt to retain 
the womb by suture would rarely, if ever, be successful. Furthermore^ 



HUPTUKE OF THE UTERUS 355 

in these cases the danger of rupture of the womb in subsequent par- 
turition would be very great. If, however, the tear is not extensive, 
and a portion of the fetus only has escaped from the uterus, an assist- 
ant should deliver the child through the vagina, or the operator may 
deliver the fetus by incising the uterus longitudinal)}- in the median 
line, then closing the incision, and suturing the tissues at the site of the 
rupture. If the rupture has been extensive and the edges of the torn 
uterine muscle have retracted considerably, the attempted suture will 
be attended with gi*eat risk and will often end in disaster. Under 
such circumstances hysterectomy, with the removal of the Fallopian 
tubes and one or both ovaries, should be performed. If the patient 
be near the menopause, both ovaries may be removed to advantage; 
and if tliis be not the case, one ovary at least should be left. Where 
labor has been prolonged, and the attempts at delivery have been made 
through the vagina, the mucous membrane and the cervix at its cut 
edges should be cauterized with carbohc acid, followed by the apphca- 
tion of alcohol. The cervical tissues should be closed with buried 
catgut stitches, and the edges of the broad ligaments should be brought 
together by continuous suture, and also the peritoneal edges, to 
cover the stump. The tubes may be dissected out and the uterine 
tissues at their internal extremity be brought together with catgut 
sutures. 

If the obstetrician fears that septic infection has occurred, he should 
place a gauze drain at the bottom of the pelvis behind the stump, 
emerging at the lower end of the abdominal incision. The lowest 
stitch of this incision should be left untied : and the tissues brought 
together after the removal of the drain. In cases of extensive rupture 
the tear may extend laterally into the broad ligaments and it may be 
necessary to ligate the veins of the broad Ugaments separately. 
Care should be taken to bring together the tissues accurately, and if 
the operator fears that subsequent hemorrhage may occur, he ma}^ 
place additional gauze where the hemorrhage is feared, removing it 
forty-eight hours after the operation. It is often best not to introduce 
salt solution into the abdominal cavitv in these cases, as such solution 



356 OPERATIVE OBSTETRICS 

might spread infection from the pelvis among the intestines. Intra- 
venous sahne transfusion during operation will give better results. 

In dealing with cases where the w^omb has been torn by unsuccessful 
attempts at delivery the lacerations will be through the lower uterine 
segment, as a rule, and may open into the vagina as well. Such in- 
juries, if not extensive, may sometimes be repaired by suture, a gauze 
packing introduced beliind the womb, and the effort made to retain 
the uterus. Where extensive laceration has occurred at the side of 
the uterus thi^ough the cervix, considerable extravasation of blood 
will often follow, and hematoma or hematocele may develop. 

Should the case be infected before operation and the laceration 
be irregular in contour, and extending into the sides of the uterine 
tissue and into the pelvic tissues as well, the complete removal of the 
uterus is indicated. In these cases the torn vaginal and pelvic tissues 
may be brought together b}' suture and a gauze drain introduced 
and carried through into the vagina. The abdomen may then be 
closed from above, and the gauze removed through the vagina 
subsequently. 

The Mortality and Morbidity of Uterine Rupture. — Among recent 
papers on the subject, Lobenstine ^ collected 37 cases in 41,800 labors. 
The accident happened more frequently in multigTavidse. Internal 
podalic version in the presence of uterine contraction is a frequent 
cause, and pelvic contraction has long been recogTiized as the most 
frequent complication leading to the accident. 

In the 37 cases of complete rupture quoted, the mortality was 73 
per cent.; 23 were treated by hysterectomy, with a mortality of 60 
per cent.; 14 by packing, with a mortality of 92 per cent. 

Eversmann - reports 140 cases, of whom more than one-half recov- 
ered ; 45.8 per cent, died ; 2 of these deaths were caused by gangrene 
of the intestine, resulting from pressure. When cases were selected 
for abdominal section the mortality was 42.8 per cent. ; when abdomi- 
nal section was done indiscriminately on all cases, the mortality of 

^ Bulletin of the Lying-in Hospital of the City of Xew York, March, 1907 
- Archiv f. Gynakologie, Band 76, Heft 3, 1905. 



HlTTrHP] OF THE UTERUS 357 

those so treated was considerably over .30 per cent.; death residt(>d 
from peritonitis in 57 pcv cent.; from bleeding in 43 per cent. 

It is interesting to note that the mortality rate was lower in 
the homes of patients than in cases transported to hospital; 29 per 
cent, more patients recovered without transportation. When, how- 
ever, the patient was promptly removed to the hospital as soon as the 
accident happened, before the child was removed, the mortaiit}' was 
increased 8.1 per cent. Eversmann has found that 8o per cent, of 
cases could be successfully treated by the tampon, and that 15 per 
cent, demanded abdominal section. 

The cases operated upon by vaginal hysterectomy gave 44 per 
cent, of recovery; abdominal hysterectomy, 46 per cent, of recov- 
ery; abdominal extirpation gave 46 per cent, of recovery; and suture 
of the uterine muscle through the abdomen 53 per cent, of recoveries. 

In 13 cases observed by Kerr,^ 2 died without operation; 3 cases of 
incomplete rupture were vSuccessfuUy treated by the use of the tam.- 
pon; the Porro operation was unsuccessfully performed in 1 case; in 
5 celiohyst erect omy gave 2 recoveries and 3 deaths; and in 3 the uterus 
was extirpated, with 1 recovery and 2 deaths. 

Schiitte ^ in 14 cases — 8 complete and 6 incomplete — had 3 deaths, 
1 from complete rupture and 2 from incomplete. He has seen the best 
results from abdominal section followed by extirpation of the uterus, 
with vaginal drainage. 

Scipiades,^ in 97 cases, found the mortality 65.8 per cent. He 
considers it essential that the patients be disturbed as little as pos- 
sible in transportation. In competent hands there seemed ver}' little 
difference between the conservative treatment with the tampon and 
operation. 

The Recent Bibliography of Rupture of the Uterus 

Albeck: Ugeskrift fiir Laeger, p. 1030, 1907. 

Blumreich: Berliner klin. Wochenschrift, Xo. 28, p. 890, 1907. 

^ British Medical Journal August 24, 1907. 

- Monatsschrift f. Geburtsliiilfe und Gynakologie, Band 26, Heft 2, 1907. 

3 Zentralblatt f. Gynakologie, No. 26, 1907. 



358 OPERATIVE OBSTETRICS 

Brodhead and Brikner: American Journal of Obstetrics, December, 

1909. 
Brown: Journal of American Medical Association, October 24, 1908. 
Cohn: Zentralblatt f. Gynakologie, p. 327, 1907. 
Conrad: Zentralblatt f. Gynakologie, p. 24, 1907. 
Couvelaire: Zentralblatt f. Gj'-nakologie, No. 48, 1907. 
Cripps: British Medical Journal, June 2, 1906. 
Donaldson: Surgery, Gynecolog}^ and Obstetrics, April, 1908. 
Eden: Journal of Obstetrics and Gynecology' of the British Empire, 

June, 1909. 
Ehrendorfer: Archiv f. Gynakologie, Band 86, Heft 2, 1908. 
Eisenstein: Zentralblatt f. Gynakologie, Xo. 27, 1908. 
EUiot : British Medical Journal, March 7, 1908. 
Everke: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 26, p. 

261, 1907; Zentralblatt f. Gynakologie. Xo. 26, 1907. 
Falk: Zentralblatt f. Gynakologie, Xo. 41, 1909. 
Franz: Zentralblatt f. Gynakologie, Xo. 18, 1908. 
Freidberg: St. Petersburg Med. Wochenschrift, Band 32, p. 157, 1907. 
Freund: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 65, p, 735, 

1909. 
Hafner: Inaug.-Diss., Breslau, 1910. 
Hartmann : Zeitschrift f . Geburtshiilfe und Gynakologie, Band 62, Heft 

3, 1908. 
Holm: Gyn. Rundsch., Band 1, p. 585, 1907. 
Jolly: Zeitschrift f. Geburtshiilfe unci Gj-nakologie, Band 60, Heft 3, 

1907; Zentralblatt f. Gynakologie, Xo. 49, 1907. 
Karnicki: Prezegl. lekarski, Xo. 37, 1907. 
Lea: Journal of Obstetrics and Gynecology' of the British Empire, 

December, 1904, and October, 1909. 
Ledomsky: Journal of Obstetrics and Gynecology, St. Petersburg, Jan- 
uary and February, 1909. 
Leverich: Orvosi Hetilap, Xo. 52, 1907. 

Lobenstine: American Journal of Obstetrics, Xovember, 1909. 
Mulert: Deutsche med. AVochenschrift, Xo. 37, 1907. 
Petren: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 29, Heft 

3 and 4, 1909. 
Potocki: Ann. de Gyn. et d'Obstet., June, 1906. 
Puech: Zentralblatt f. Gjniakologie, p. 323, 1907. 
Salms: Zentralblatt f. Gynakologie, Xo. 34, 1909. 
Sandberg: Inaug.-Diss., Freiburg, 1909. 
Schiitte: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 29, 

June, 1909. 



INVERSION OF THP: UTERUS 359 

Scipiades: Zentralblatt f. (iynakologie, Xos. 13 and 40, 1009. 
Sitzenfrey: Moiiatssclirift f. Geburtshiilfe und Clyniikologie, Band 30, 

Heft 1, 1909. 
Small: American Journal of Obstetrics, vol. 55, p. 653, 1907. 
Smith: Journal of Obstetrics and Gynecology of the British Empire, 

Xo. 6, June, 1909. 
Stutz: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 26. p. 257, 

1907. 
Tissier and David: Zentralblatt f. Gynakologie, X'o. 45, 1907. 
Valeiy: Inaug. -Dissert., Paris, 1905. 

Walthard: Verh. d. deutsch. Ges. f. Gyn., Band 12. p. 626, 1907. 
Weber: Beitr. Z. Geb. u. Gyn., Band 15, p. 53, 1909. 
Westermark: Hygiea, p. 768, 1907. 
Zangemeister : Miinchener med. Wochenschrift, Xo. 27, p. 1344, 1907; 

Zentralblatt f. Gynakologie, Xo. 32, 1907. 

Inversion of the Uterus 

As the name indicates, this accident consists in the prolapse of 
the uterine fundus, the turning in of the uterine body, and the descent 
into the vagina or through the ^ailva of the uterus inverted, dragging 
with it into the pelvic cavity the tubes and ovaries. 

Conditions Predisposing to Inversion of the Uterus. — Adhesions, 
scar tissue, and scars following operations about the cervix and lower 
uterine segment sometimes predispose to inversion. Chronic endo- 
metritis of the uterine decidua during pregnancy, with adhesion of the 
placenta, are potent factors in causing this accident. The relaxed 
condition of the muscular tissue of the uterus and exhaustion of the 
uterine muscle in long-continued or difficult labor predispose to its 
occurrence. 

The Immediate Causes of Inversion of the Uterus. — Traction upon 
the wall of the uterus near the fundus is the most potent factor in 
producing this accident. Before Crede's method of expressing the 
placenta was introduced, and the placenta was frequently delivered 
by pulling upon the umbilical cord, inversion of the uterus was far 
more frequent. Failure of the placenta to separate normally, accom- 
panied by traction upon the cord, readily brings about the accident. 

The improper application of Crede's method in recent times has 



360 OPERATIVE OBSTETRICS 

frequently inverted the womb. If the obstetrician depresses or 
dimples the fundus of the uterus, and continues to press downward 
upon the fundus, inversion may often result. 

Whether from traction upon the cord or dimpling of the fundus 
by pressure, the mechanism of uterine inversion is practically the 
same. Contraction and retraction of the uterine muscle being im- 
perfect because the uterus is not completely emptied, the fundus 
is brought by traction or pressure downward toward the lower uterine 
segment. This manipulation excites contraction of the uterine ex- 
pulsive segment, and sufficient pain is caused to produce bearing clown 
and struggling on the part of the patient. An inverted uterine peris- 
talsis results, and the fundus descends through the lower uterine seg- 
ment and cervix. 

Unless the fundus be promptly returned to its normal position, the 
contraction of the cervix may render the inversion permanent. The 
lower edge of the upper uterine segment will also contract, fm'nishing 
an additional obstacle to replacement. 

Inversion of the Uterus Caused by Tumors Complicating Preg- 
nancy. — Submucous fibroids complicating pregnancy may bring about 
inversion of the uterus after the delivery of the cliild. The relaxed con- 
dition of the cervix and lower uterine segment is favorable for this 
accident. During labor the fibroid becomes pedunculated and after 
the birth of the child descends into the uterine cavity. Its presence 
may excite uterine contraction, while the attachment of its pedicle 
to the fundus drags down the fundus and finally brings about in- 
version. 

Signs and Symptoms of Uterine Inversion. — Shock and hemor- 
rhage following the expulsion of the child may indicate inversion of 
the uterus. The absence of the uterus above the pubes, a tumor in 
the vagina or protruding from the M.ilva, and the persistence of shock 
and collapse indicate the accident. The placenta may remain 
adherent to the fundus of the uterus and disginse the presence of the 
fundus until a thorough examination is made. A pedunculated 
fibroid appearing at the yiiIysl may conceal the presence of the fundus 



INVERSION OF THE ITEIJUS 301 

just above. Mistakes have been made in diagnosticating the 
tumor, and the uterus has been removed, supposing that a fibroid 
presented or that the placenta was so adherent that it could not be 
removed. 

The Results of Uterine Inversion. — If the patient's power of resist- 
ance be lessened by exhausting labor and anemia, the shock and 
hemorrhage accompanying inversion of the uterus may prove rapidly 
fatal. Infection may readily occur, especially at the placental site, 
and sepsis may turn the scale against the patient. Robust women 
survive inversion of the uterus, but health is impaired and the patient 
suffers from disability. The uterine mucous membrane becomes in- 
fected, the abnormal position of the ovaries causes pain and distress, 
the functions of the bladder are interfered with, the patient is unable to 
move freely, and her general health is greatly deranged. Should 
infection become severe, death from sepsis will follow. 

The Prophylaxis of Uterine Inversion. — The obstetrician should 
make it his rule to avoid, under all circumstances, pulling upon the 
umbilical cord while the placenta is attached to the w^all of the uterus. 
Tong and exhausting labor should be terminated promptly and care 
should be taken that Crede's method of expression be applied by 
making pressure upon the anterior and posterior walls of the uterus 
without indenting the fundus. 

Treatment. — In the presence of immediate inversion, the placenta, 
if attached, should first be removed. The uterus should be irrigated 
with 1 per cent, lysol, and the effort made with the closed gloved hand 
to indent the fundus and carry the womb upward to its accustomed 
position. 

Complete anesthesia will be necessary. If the fundus can be 
indented sufficiently to permit one or two knuckles of the fist to be 
inserted, and if pressure be steadily made in the axis of the pelvis, the 
operator may hope for success. Some prefer to place a pad of gauze 
over the fist to avoid the danger of pressure upon the uterine mucous 
membrane. After replacement, the uterus should be irrigated with 
hot lysol solution and packed with gauze, and the vagina tamponed 



362 OPERATIVE OBSTETRICS 

also. Tonic doses of strychnin and ergot should be given to prevent 
relaxation and hemorrhage. 

Where the uterus cannot be replaced, if the circumstances are favor- 
able for maintaining asepsis, the operator may wait until the patient 
has recovered from the immediate shock of fatigue and labor, and 
may then, under anesthesia, make a further trial. 

Where the uterus cannot be replaced and becomes infected dur- 
ing the puerperal period, its removal by vaginal section is indicated. 
If the conditions are favorable, the effort should be made to preserve 
one or both ovaries. If the tubes can be conveniently reached they 
should be removed. The pelvic cavity should be drained with gauze 
and the broad ligaments closed by continuous catgut suture. 

In chronic inversion of the uterus various methods of treatment 
have been employed. 

The effort has been made by persistent pressure to indent the 
fimdus and thus restore the uterus to its normal condition. Pressure 
for some time with a hard-rubber ovoidal bulb has caused the uterine 
muscle to yield and brought about replacement. 

Operative measures addressed to the relief of chronic inversion 
have endeavored to dilate or cut the contraction-ring, which prevents 
the ascent of the fundus and thus brings about its return to a normal 
position. 

The choice of a method of treatment must depend largely upon 
the general condition of the patient, and especially upon the condition 
of the uterus and its lining membrane. If this be healthy, and infec- 
tion be absent, operative treatment may be undertaken with hope 
of success. If, however, the uterus has become infected, or if it be 
the site of a foreign growth, vaginal hysterectomy is indicated. 

In cases where inversion of the uterus has occurred, and the 
patient has been successfully operated upon with retention of the 
womb, subsequent labor may be followed by postpartum hemor- 
rhage. 

Born ^ successfully operated for chronic inversion, the patient 

1 Zentralblatt f. Gynakologie, No. 4, 1907. 



INVERSION OF THK ITEKUS 363 

recovering, and chronic lu^niorrliage being succeeded by menstrua- 
tion. Pregnancy occurred and went successfully to full term. The 
labor was rapid and spontaneous, but the separation of the placenta 
was followed by hemorrhage, from which the patient recovered. 

Keilmann^ rc})oi*ts a similar case, in which profuse hemorrhage 
occurred from partial separation of the placenta, which had been at- 
tached to the anterior uterine wail. The manual removal of the 
placenta was followed by cessation of the hemorrhage. 

The Recent BiBLiociRAPHY of Ixversiox of the Uterus 

Andrews: Transactions of the Obstetrical Society of London, vol. 48, 

1906. 
Barbour: Journal of Obstetrics and Gynecology of the British Empire, 

October, 1906. 
Baseil: British Medical Journal, July 17, 1909. 
Boissard: Bull, de la Soc. d'Obstet. de Paris, No. 10, p. 299, 1907. 
Born: Zentralblatt f. Gynakologie, No. 4, 1907. 
Brammer: Montasschrift f. Geburtshiilfe und Gynakologie, Band 26, 

Heft 1, 1907. 
Cache: Annal. de Gyn., October, 1907. 
Clarkson: British Medical Journal, March 6, 1909. 
Dighton: Journal of Obstetrics and Gynecology of the British Empire, 

October, 1905. 
Ferguson: Journal of Obstetrics and Gj^necology of the British Empire, 

October, 1906. 
Fritsch: Zentralblatt f. Gynakologie, No. 16, Band 31, p. 427, 1907. 
Gross: Zentralblatt f. Gynakologie, No. 46, 1907. 
Guggisberg: Zentralblatt f. Gynakologie, No. 3, 1909. 
Hewson: Annals of Gynecology and Pediatrics, January, 1907. 
Holthusen: British Medical Journal, January 23, 1909. 
Holzapfel: Miinchener med. Wochenschrift, Band 54, p. 1504, 1907. 
Josephson: Zentralblatt f. Gynakologie, No. 25, 1907. 
Konietzny: Inaug.-Diss., Breslau, 1907. 
Lichtenstein : Zentralblatt f. Gynakologie, No. 43, 1907. 
MacLean: Journal of Obstetrics and Gynecology of the British Empire, 

April, 1906. 
Meriel: Annal. de Gyn., April, 1909. 
Neugebauer: Zentralblatt f. Gynakologie, No. 47, 1906. 

1 Zentralblatt f. Gynakologie, No. 13, 1907. 



364 OPERATIVE OBSTETRICS 

Olmstedt: Journal of American Medical Association, vol. 48, No. 6, 

1907. 
Peterson: Surgery, Gynecolog}^ and Obstetrics, August, 1907. 
Pixis: Inaug.-Diss., Wurzburg, 1907. 

Priismann: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 60, 1907. 
Schonbeck: Zentralblatt f. Gynakologie, No. 32, 1908. 
Tate: Journal of Obstetrics and Gynecology of the British Empire, 

March, 1907. 
von Herff : Zentralblatt f. Gynakologie, Band 30, p. 425, 1907. 



PART III 



THE SURGERY OF THE PUERPERAL PERIOD 



THE REMOVAL OF THE PLACENTA 

The removal of the placenta by Crede's method is so successful 
in the majority of cases that the insertion of the hand into the uterus 
for this purpose is not often necessary. Circumstances ma}- arise, 
however, which make it much safer to remove the placenta manually 
than to employ Crede's method. 

Indications for Manual Removal of the Placenta. — Premature de- 
tachment of the placenta accompanying or immediatelj^ following the 
extraction of the fetus may give rise to active hemorrhage threaten- 
ing the child and the mother as well. Crede's method may prove 
inefficient because sufficient time has not elapsed to permit the closing 
of the uterine sinuses and prepare the placenta for its expulsion. 
Tnder these circumstances its prompt removal, followed by tampon- 
ing the uterus with 10 per cent, iodoform gauze, will immediately 
check the hemorrhage. The hypodermic administration of strychnin 
and ergot will render the uterine contractions efficient and lasting. 

In cases where difficult delivery, accompanied or immediately 
followed by considerable hemorrhage, has led the operator to fear that 
laceration of the lower uterine segment or, possibly, rupture of the 
uterus has occurred, the removal of the placenta manually is indicated 
to secure prompt uterine contraction and to permit the operator to 
examine the interior of the uterus manually. It can then be decided 
whether the threatening hemorrhage can be averted by the tampon, 

365 



366 



OPERATIVE OBSTETRICS 



or by sutures at the upper portion of the cervix, preceded by the 
tampon. 

Wherever there is a reasonable suspicion that portions of the pla- 
centa remain behind, and the operator is working under competent 
aseptic precautions, the uterus should be explored and such fragments 
immediately removed. 




Fig. 221. — Manual removal of the placenta (Bumm). 



Methods of Removing the Placenta. — The hand to be inserted with- 
in the uterus should have been prepared as for abdominal section and 
covered with a sterile rubber glove. The use of the obstetric gauntlet, 
reaching to the elbow, may be advantageous, but difficult to carry out. 
As a rule, an ordinary glove suffices, as the uterus may be pressed 



THE REMOVAL OF THE PLACENTA 



307 



down into the pelvic cavity, thus enabling the operator to reach the 
placenta without carrying the unguarded forearm within the cervix. 
The antiseptic preparation of the forearm, r(^aching above the elbow, 
is imperative in all obstetric manipulations. In introducing the 
hand the operator can usually recognize the fetal as})ect of the pla- 
centa. This he will avoid, as he wishes to pass his fingers between the 
placenta and the uterine wall, as a paper-cutter is inserted between the 
leaves of a book. Finding the placental edge, he thus separates the 
placenta, passing the fingers gently until he feels that it has been 
entirely loosened. Then, grasping it in the hand and rotating it gently. 




Fig. 222. — Delivering the membranes (Bumm). 



he draws the placenta out, the membranes being twisted into the 
cord as they emerge. Retained blood-clot should be removed after 
the placenta has been delivered. 

Precautions in Delivering the Placenta. — If the operator is hasty 
and unfamiliar with the anatomy of the placenta and uterus, he may 
remove only a portion, leaving a considerable part behind. Where 
the statement is made that the placenta has been completely adherent 
in a given case, it is more than probable that the operator failed to exer- 
cise patience in passing the fingers between the placenta and the 
uterine wall. In cases exhausted by hemorrhage or infected the 
fingers might be carried through the uterine wall, and hence the 



368 OPERATIVE OBSTETRICS 

finger-tips should be turned toward the placental substance as the 
separation proceeds. Should the operator find a foreign body within 
the uterus which he cannot recognize, after deUvering the placenta, 
membranes and blood-clots, he can draw this gently down sufliciently 
far to inspect it. In cases of uterine rupture the intestine is often pro- 




Fig. 223. — Manual removal of the placenta (Kerr), 

lapsed into the uterus and has been pulled down and torn by efforts 
at placental dehvery. 

Delivery of the Placenta After Uterine Rupture.— In rupture of the 
uterus, should the child escape entirely into the abdominal ca\4ty, a 
portion of the placenta may also be extruded. Here the introduc- 



THE REMOVAL OF THE PLACEXTA 



369 



tion of the hand to deliver the placenta is especially valuable, as it 
enables the operator to locate and examine the rent and to make a 
satisfactory diagnosis. 

The Delivery of the Placenta in Twin Labor. — Shoidd it be necessary 

to deliver the placenta of the first fetus in twin labor, the operator 




Fig. 224. — Sho^\-ing portion of the uterine wail and attaciied placenta. The 
circular sinus is very distinctly seen. Drawing from a specimen in the Hunterian 
Museum, Glasgow University iKerr). 



should be careful not to disturb the second placenta, if they be separ- 
ated. If there be one large placenta, delivery should not be under- 
taken until the second twin has been born. Especial care should be 
taken in these cases to separate the placentae completely and to avoid 



24 



370 OPERATIVE OBSTETRICS 

forcible manipulation, because the uterus is overdistended and may 
readily rupture. 

Delivery of the Placenta by Pulling Upon the Umbilical Cord. — 

Under no circumstances should this procedure be adopted. It has 
caused inversion of the uterus with fatal results. In some cases the 
operator may grasp the cord with one hand, holding it as a guide to the 
introduction of the hand to the maternal surface of the placenta, but 
considerable traction upon the cord should not be made. 

The removal of the placenta and retained blood-clot should inva- 
riably be followed by palpation of the uterus to determine the presence 
or absence of rupture. Should this be present, in whatever degree, 
the uterus should not be irrigated to control hemorrhage. The diag- 
nosis of the existence and extent of uterine rupture can only be made 
by introducing the hand within the womb or by opening the abdo- 
men. 

Bibliography of Delivery of the Placenta 

Adler: Monatsschrift f. Geburtshiilfe und Gj^nakologie, Band, 25, 1907. 
Adler and Kraus : Monatsschrift f . Geburtshiilfe und Gynakologie, Band 

25, Heft 6, 1909. 
Ahlfeld: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 64, 1909. 
Beatus: Zentralblatt f. Gynakologie, No. 47, 1907. 
Burkhard: Zentralblatt f. Gynakologie, No. 14, 1909. 
Durlacher: Miinchener med. Wochens., No. 8, 1907. 
Gans: Gyn. Rundschau, p. 66, 1909. 
Gauss: Hegar's Beitr. z. Geb. u. Gyn., Band 15, 1909. 
Guenot: Zentralblatt f. Gynakologie, p. 56, 1907. 

Hartmann: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 65, 1909- 
Herzfeld : Archiv f . Gynakologie, Band 82, 1907. 
Hofmann: American Journal of Obstetrics, p. 631, 1909. 
Hofmeier: Berliner klin. Wochens., No. 12, 1907. 
Hohne: Zentralblatt f. Gynakologie, No. 10, 1909. 
Ihm: Inaug.-Diss., Heidelberg, 1907. 
Jacobson: Zentralblatt f. Gynakologie, No. 33, 1907. 
Kamann: Zentralblatt f. Gynakologie, No. 26, 1907. 
Kronig: Deutsche m. Wochenschrift, No. 46, 1909. 
Labhardt: Proceedings German Gynecological Society, vol. 13, 1909. 
Leo: Munchener m. Wochenschrift, No. 31, 1909; Beitr. Z. Geb. u. Gyn., 

Band 15, 1909. 



THE CONTROL OF HEMORRHAGE DURING LABOR 371 

Pfannenstiel and Thies: ^lonatsschrift f. Geburtshiilfe und (Jynakologie, 
Band 29, Heft 3, 1909. 

Puppel : Zeitsc'hrift f . Geburtshiilfe und Gynakologie, Bands 64 and G5, 
1909. 

Richard: Zentralbhitt f. Gynakologie, Xo. 33, 1907. 

Richter: Zentralblatt f. Gynakologie, Xo. 22, 1909. 

Rielander: Zentralblatt f. Gynakologie, Xo. 28, 1909. 

Scheffen: Miinchener m. Wochenschrift, X'o. 47, 1909. 

Sellheim: Zentralblatt f. Gynakologie, Xo. 26, 1907; G}ti. Rundschau, 
p. 61, 1909. 

Sigwart: Zentralblatt f. Gynakologie, Xo. 7, 1909; Archiv f. Gyna- 
kologie, Band 89, 1909. 

Tissier: Zentralblatt f. Gjmakologie, p. 56, 1907. 

Veit : Zentralblatt f. Gynakologie, Xo. 32, 1909. 

Weber: Zentralblatt f. Gynakologie, Xo. 41, 1909. 

Wright: American Journal of Obstetrics, Xovember, 1906. 

THE CONTROL OF HEMORRHAGE DURING LABOR 

Hemorrhage may occm' during labor from wounds in the lower 
uterine segment or cervix. When the tissues are abnormal or altered 
by some previous pathologic condition, resistance to dilation is present 
at the internal os, the cervix and lower uterine segment instead of 
dilating may tear, opening branches of the uterine artery. This is 
especially seen in primiparous patients with undeveloped cervix and 
congenital occlusion at the external os. 

The writer, on one occasion, was called in consultation by physicians 
who were conducting a case in the first stage of labor. The uterine 
contractions were strong, the cervix had become obliterated, but 
the external os could not readily be found and was congenitally oc- 
cluded. On examination, a tear extended along the cervix near the 
vaginal junction, separating the muscular fibers obliciuely in an irreg- 
ular manner. The external os was found drawn upward and back- 
ward, admitting the curved director. This was gradually dilated 
until the finger could be inserted, the cervix then incised, making 
four flaps, when the head descended and labor terminated. The 
bleeding stopped as soon as the cervix was opened. 

Hemorrhage may also occur during labor from deep tears of the 



372 



OPERATIVE OBSTETRICS 



cervix following the passage of the presenting part. Such hemor- 
rhage is not usually considerable until after the birth of the child, 




Fig. 225. — Accidental hemorrhage in which the bleeding is partly concealed and 
partly apparent. Mixed variety (Kerr). 

although it begins during actual labor and will continue until the 
uterus is empty. 

As the head descends upon the pelvic floor, if the patient be un- 
developed and expulsive efforts be vigorous and sudden, the pelvic 



THE CONTROL OF HEMORRHAGE DURING LABOR 



373 




Fig. 226. — Complete or central placenta prsevia. Photographed from Van 
Rymsdyk's drawing in the Hunterian Museum, Glasgow University (Kerr). 



floor and perineum will tear before the head. Such lacerations 
rarely occasion serious hemorrhage at the moment of birth, but may 



374 



Umbilical cord 



OPERATIVE OBSTETRICS 




Anterior vaginal 
wall 



Limit of placen- 
tal detach- 
ment 



Bleeding pla- 
cental tissue 



External os 



Fig. 227. — The souro^ of bleeding in placenta prsevia (Bumm). 




Internal 03 



Fig. 228. — Vaginal tampon in placenta prsevia (Bumm). 



THE CONTROL OF HEMORRHAGE DURIXG LABOR 



375 



cause persistent bleeding afterward, requiring suture. It is rarely 
necessary to tie the vessels or take the stitches during labor. Should 
it be evident that the passage of the head will cause serious and deeper 
lacerations in the pelvic floor and perineum, unilateral or bilateral 
episiotomy should be promptly done and the child speedily delivered. 
In undeveloped primipane the anterior segment of the pelvic floor may 




Fig. 229. — Excessive distention of the anterior lip of the cervix, the external 
OS but little dilated, and torn high up posteriorly (Kerr). 

tear in the vicinity of the urethra as the head descends. The location 
of the tear should be noted and it should be closed by suture as soon 
as labor has terminated. Severe hemorrhage may occur during 
labor from the bursting of varicose veins in the vidva. A catgut 
ligature should be deeply passed with a curved needle, compressing 
and occluding these veins; or, if haste be imperative, hemostatic 
forceps may be applied. 



376 OPERATIVE OBSTETRICS 

THE CONTROL OF HEMORRHAGE AFTER LABOR (POSTPARTUM 

HEMORRHAGE) 

Following the delivery of the child active hemorrhage may occur 
from the uterine sinuses through relaxation of the uterine muscle. 
This occurs naturally in those cases where the uterine muscle has 
become exhausted from long and ineffectual labor. If this be the 
only cause present, hemorrhage will promptly cease when the uterus 
is empty and its muscle is stimulated to contract. Manual com- 
pression of the uterus, accompanied by massage, an intra-uterine 
douche of hot 1 per cent, lysol or salt solution, and the hypodermic 
injection of jt gr- of sulphate of strychnin and 60 minims of aseptic 
ergot, will in most cases promptly check this hemorrhage. If this 
result does not follow, the intra-uterine tampon with 10 per cent, 
iodoform gauze will be found efficient. 

In cases where it is necessary to remove the placenta manually to 
terminate a complicated labor, the operator must choose between the 
immediate use of the tampon or delay, to permit the other methods 
already described to accompHsh their purpose without the tampon. 
If the operator has good facilities for asepsis and antisepsis, we 
believe, in the long run, it is wiser to anticipate hemorrhage after the 
manual removal of the placenta, and to immediately follow^ its extrac- 
tion by the hot antiseptic intra-uterine douche, succeeded by the 
uterine tampon with 10 per cent, iodoform gauze. 

Two methods of packing the uterus with gauze are available: 
If the operator has few assistants he will do well to insert the left hand 
within the vagina while an assistant presses the uterus downward into 
the cavity of the pelvis. The gauze may then be passed with long 
curved uterine dressing forceps nto the cervix along the palm of 
the hand within the vagina, and carried by the forceps into the body 
of the womb. When considerable gauze has accumulated there it 
should be tightly packed by the longest fingers of the hand within 
the vagina, pushing the gauze firmly into the ca\dty of the uterus 
and completely filling the upper expulsive uterine segment. If the 
operator trusts to his forceps alone he may carry but a portion of the 



THE CONTROL OF HEMOKUHAGE AFTER TABOR 



377 



gauze into the iip})or part of the womb, distending tlie lower uterine 
segment with the remainder. This will result in a faulty applica- 
tion of the tampon and will further the formation of a large clot above 
the lower uterine segment, which will favor the continuance of bleed- 
ing. If the uterus be properly packed the bleeding is immediately 
controlled. 




Fig. 230. — Tamponing the uterus with gauze (Bumm). 



If the operator has abundant assistance he may grasp the edge 
of the lips of the cervix with uterine tenaculum forceps and draw 
them gently downward toward the vulva. Sterile gauze may then be 
packed around the cervix as a dentist places sheet rubber around the 
cavity of the tooth which he has prepared for filling. In this way 
the gauze is protected from the vulva and vagina in its passage into 
the uterus. The iodoform gauze can then be inserted by the forceps 



378 



OPERATIVE OBSTETRICS 



through the cervix to the fundus and the uterus packed under direct 
vision. This method, however, is not available unless there be suffi- 
cient assistants to hold the limbs in position, and also to hold one of 
the tenaculum forceps while the operator grasps the other. 

The objections to the use of antiseptic gauze within the womb 
are the danger of infection through contamination of the gauze 
by the ^oilva and vaginal tissues, and the danger of w^ounding the 
uterus or perforating it during the insertion of the gauze. 




Fig. 231. — Genital tract correctly Fig. 232. — Genital tract improperly tam- 

tamponed (Bumm). poned. Piece of placenta left in uterus 

(Bumm). 

The writer and his assistants have for some time practised the use 
of the intra-uterine tampon, and in no case so far have we met with 
these complications. In one case in the experience of the wTiter a 
clot accumulated at the fundus above the gauze and w^as discharged 
when the gauze was removed. It gave rise to no symptoms and its 
presence was not suspected. In our experience the intra-uterine 
use of the tampon has two advantages: It checks hemorrhage, 
preventing the accumulation of clots which might become infected, 



THE CONTROL OF HEMORRHAGE AFTER LABOR 



879 



and might also cause painful utrrine contractions or after-pains. 
The gauze acts as an antiseptic drain to the uterus and prevents the 
development of infection. In our experience the advantages of this 
method far outweigh its possible objections. 

In cases comi)licated by toxemia it may be very difficult to check 
bleeding from the uterus occurring after labor. The coagulability 
of the blood in these cases is so lessened by the toxemic condition that 




Fig. 233. — Manual tamponing of the uterus (Bumm). 

the blood does not clot, and pressure is not efficient in completely 
checking hemorrhage. In these cases the use of adrenalin (1 : 1000) 
may prove advantageous, and it may be necessary to renew the 
uterine tampon to control bleeding. In extremely toxemic patients 
it may be impossible to control hemorrhage, and the patient may 
die as a consequence. 

The effort has been made to control uterine hemorrhage after 
labor by applying clamps to lacerations in the cervix and leaving 
them in position for a number of hours. While this method may 



380 OPERATIVE OBSTETRICS 

be successful in some cases, it is more dangerous and less efficient 
than the tampon properly appUed. 

In cases where hemorrhage is severe and death threatens, it may 
be necessary to completely arrest hemorrhage from the pelvic vessels 
by manual compression of the abdominal aorta or its branches at its 
bifurcation. 

The experience of the writer may serve to illustrate this method : 
An anemic multipara was admitted to the Jefferson Maternity, having 
bled severely from accidental separation of the placenta. The cervix 
was partly dilated, an eight-months' fetus was within the womb, 
and the patient was pulseless. She was hastily placed in position, 
and while her arm was prepared for intravenous saline transfusion 
the writer emptied the uterus promptly by manual dilation and ex- 
traction of the uterine contents. The hand was introduced within 
the womb and tightly closed and the fist carried up within the uterine 
fundus to the brim of the pelvis. The knuckles wTre then pressed 
firmly against the branches of the abdominal aorta near its bifurca- 
tion, and the circulation of the pelvis practically arrested. This 
pressure was continued until intravenous saline transfusion could be 
given, and hypodermic stimulation. Without removing the hand 
a glass douche tube was then introduced within the uterus, and its 
cavity irrigated with hot salt solution. While the uterus was com- 
pressed through the abdominal wall the hand was removed and 
the uterus securely packed with 10 per cent, iodoform gauze. The 
hemorrhage was thus controlled and the patient recovered. 

In our experience this has been a more efficient method than the 
device advised by Momburg, described in a recent paper by Sigwart.^ 
Sigwart's method consists in passing a strong elastic band around the 
abdomen above the pelvic brim and practically applying a tourniquet 
to the abdominal aorta. He describes 19 cases in which this device 
was used to check hemorrhage until some other method could be 
employed for its permanent arrest. 

In cases of severe hemorrhage from the body of the uterus after 

1 Archiv f. Gynakologie, Band 89, Heft 1, 1909. 



THE CONTROL OF HEMORUHAGIO AFTIOK LABOR 3(S1 

labor, aithough the operator may succeed in checking tlie bleeding, 
he must be prepared for secondary shock and hemorrhage within a 
few hours. Usually it is possible to control this by hypodermic stim- 
ulation without disturbing the intra-uterine tampon. 

In the experience of the writer, an anemic multii)ara bled severely 
three times within four days following her delivery. It was necc^s- 
sary on each occasion to renew the uterine tampon, in addition to the 
employment 6f other means. The patient finally recovered without 
infection, her recovery being complicated by a persistent anemia. 

In cases of serious uterine hemorrhage, after the means described 
have been employed, good results may be obtained by the application 
of the interrupted Faradic current, one pole being placed over the lower 
dorsal and upper lumbar region, the other pole over the uterus. 
The current may be applied from half an hour to an hour with positive 
benefit. Too much reliance cannot be placed upon adrenalin in these 
cases, as its effect is short lived, and its continued use may further the 
occurrence of hemorrhage rather than control it. 

It is the writer's belief that the introduction of ice, of vinegar, and 
of corrosive styptics within the uterus should be abandoned for the 
tampon of antiseptic or sterile gauze. In extreme cases, as has been 
said, the gloved hand is promptly efficient and enables the operator 
to apply the tampon w^hen the initial bleeding has been controlled. 

Bleeding After Labor from Rupture of the Uterus. — If uterine rup- 
ture be diagnosticated as the cause of hemorrhage, the operator must 
decide promptly whether he will open the abdomen and control the 
hemorrhage by suture or by hysterectomy, or whether he will endeavor 
to rescue the patient without abdominal section. If the rupture be 
complete and if the content of the uterus has escaped in considerable 
part into the abdominal cavity, abdominal section is indicated. When 
the fetus and its appendages have been removed, the operator must 
choose between hysterectomy and suture. If the uterus is in a healthy 
condition and the uterine muscle contracts when the w^omb is empty, 
and if the tear is not extensive, the operator may try to save the 
womb by the application of sutures. Usually two layers of catgut 



382 OPERATIVE OBSTETRICS 

will be required, and after suture the abdomen must be closed with 
the insertion of a gauze drain passed to the bottom of the pelvis behind 
the womb. 

If, on the contrary, the womb be flabby, or if the uterus be the 
site of fibroid disease or infection, hysterectomy must be chosen. If 
the patient's condition justifies it, and infection be absent, cehohys- 
terectomy with intraperitoneal treatment of the stump can be selected. 
If there is good reason to fear infection, and haste is imperative, celio- 
hysterectomy with extraperitoneal treatment of the stump (Porro 
operation) must be chosen. 

Secondary Puerperal Hemorrhage from the Uterus (Postpartum. 
Hemorrhage). — Under the term ''postpartum hemorrhage" is com- 
monly understood secondary relaxation of the womb, occurring at any 
time after the patient has apparent^ completed her labor and been 
left in good condition. This most often occurs in exhausted patients 
whose nervous and muscular energies are deficient and whose labor 
has been prolonged and often excessively painful. It is frequently 
accompanied by the accumulation of clots within the womb whose 
presence' prevents the free escape of blood through the vagina, thus 
obscuring the diagnosis and comphcating the treatment. In women 
of relaxed fiber retained postpartum hemorrhage may reach large 
proportions. 

In the experience of the wTiter, a multipara, after the birth of her 
child, was taken with labor-pains without vaginal hemorrhage, and 
asserted that a twin child was within the womb. On examination a 
clot as large as a fetal head w^as found in the uterus requiring removal 
and vigorous treatment to prevent further hemorrhage. 

As this compHcation frequently develops after the physician has 
left his patient, supposing her to be in good condition, its recognition 
and initial treatment become the duty of the nurse. Obstetric nurses 
should be especially taught to recognize this form of hemorrhage and 
to take active measures without waiting for the arrival of the physi- 
cian. It is our custom to teach the nurses at the Jefferson Training 
School to watch the uterus after labor by frequent palpation, to 



THE CONTROL OF HEMOKKHAGE AFTEIl LAI50R 08.'^ 

observe the condition of the uterine muscle, and the siz{^ of the w onil). 
The binder is not to be api)lied until the womb has contracted firmly, 
and so remains for at least one hour after labor. If the ut(^rus 
contracts slowly the application of the binder is to be accompanied 
b}' the placing of a large pad transversely across the abdomen above 
the uterus, carrying the uterus firmly down toward the pubes. The 
binder is then applied from above downward, or a many-tailed ab- 
dominal bandage may be used, such as is employed after section; but 
the nurse should not apply the binder or abdominal bandage until the 
uterus is properly contracted. The nurse should further watch the 
patient by noting her pulse, her color, her general appearance, and the 
presence or absence of thirst, air hunger, and restlessness. Should 
these symptoms develop after labor, the binder should be immediately 
removed and the nurse should massage the uterus until it is firm and 
hard. The obstetrician should at once be summoned and the nurse 
should immediately proceed to the administration of strychnin and 
ergot h3^podermically, and the giving of a copious vaginal douche 
of hot boiled water. 

We do not believe that nurses incompetent to carry out this treat- 
ment should be trusted with obstetric cases. If these measures have 
been carried out promptly, when the physician arrives he will find 
the initial hemorrhage controlled in the majorit}^ of cases. It will 
then be his responsibility to decide whether the tampon shall be 
introduced, if it has not been employed, and what measures shall be 
taken to secure permanent uterine contraction. In our experience, 
competent obstetric nurses control the simple forms of postpartum 
hemorrhage, and the physician's services are needed in the more 
complicated varieties and in the ordering of the after-treatment. 

While uterine hemorrhage may be temporarily checked after labor, 
its permanent arrest may require the obstetrician's best efforts. In 
addition to the use of the tampon, the hot vaginal douche, and the ad- 
ministration of strychnin and ergot, the patient's vital forces must 
be guarded and freeh^ stimulated to secure permanent recovery. 
The patient should be placed as nearly as possible in the Trend elen- 



384 OPERATIVE OBSTETRICS 

burg position. It is useless to raise the foot of the bed but a few 
inches. The head must be as low as possible, and beneath the base 
of the brain should be placed a hot-water bottle covered with only one 
or two layers of flannel. The limbs may be bandaged from the extrem- 
ities to the trunk, and the trunk of the body surrounded by artificial 
heat. It is well to avoid the use of stimulants by the mouth, for their 
absorption is so slow and uncertain and they may also cause nausea. 
Alcohol is not indicated in active hemorrhage. Intravenous saline 
transfusion is of great value, but care should be taken not to intro- 
duce too large a quantity. More than a pint is very rarely neces- 
sary. If the obstetrician is not prepared to carry out this treatment, 
the high rectal injection of 4 ounces of freshly made hot strong coffee, 
with 8 ounces of salt solution, will be found useful. The use of the 
interrupted electric current, one pole over the cerebellum, the other 
over the heart, will be found of great value in desperate cases. The 
inhalation of oxygen may be useful, but it is often impossible to obtain 
it promptly, and its use may frighten and disturb the patient. If 
she be anxious and excited, the hypodermic injection of morphin 
and atropin will be found most useful. Her excessive thirst may be 
met by rectal injections of salt solution, and after the hemorrhage 
has been checked 1 ounce of whiskey and 8 ounces of salt solution 
may be administered every two to four hours. When fluid is given 
by the mouth, small quantities of water containing 20 drops of aro- 
matic spirits of ammonia will be beneficial. After the uterus has firmly 
contracted, if gauze packing has been inserted, it is well to avoid the 
excessive use of ergot, as uterine contractions may be excited which 
will expel the gauze. If ^\ gr. of strychnin be given hypodermically 
every three or four hours the uterus will be maintained in tonic con- 
traction and the gauze will not be forced out. To sustain the action of 
the heart, digitaUn may be given in doses sufficiently large to produce 
the desired effect. The obstetrician must remember that hemor- 
rhage opens wide the doors for infection, and that his manipulations 
must be conducted under strict antiseptic precautions. 

Late Puerperal Hemorrhage. — Puerperal hemorrhage from the 



TH1-: CONTROL OF HEMORRHAGE AFTER LABOR 385 

uterus oceuiTing some time after labor, when tlu^ i)atient is a])i)areiitly 
convalescent, or recurring in small c^uantity but freciucntl}', must 
suggest the presence within the womb of a retained portion of placenta. 
Such hemorrhage will not cease until this has been removed. The 
obstetrician must explore the interior of the womb with the gloved 
hand or with a blunt douche curet, removing the retained tissue. 
This should be followed by the hot antiseptic douche and packing 
with 10 per cent, iodoform gauze. 

In some cases the experiment has been tried of saturating the 
gauze used for intra-uterine packing with adrenalin (1 : 1000). While 
this may seem temporarily beneficial, it has no essential advantage 
over antiseptic gauze and is of doubtful utility. The convalescence 
of a patient who has had severe uterine hemorrhage in the puerperal 
period is necessarily prolonged and calls for the treatment appropriate 
for pernicious anemia. 

One of the okler methods of checking hemorrhage, thought to be 
of great value, was the placing of the child to the breast. If the 
child will nurse vigorously and promptly this will undoubtedly cause 
uterine contractions, but in many cases it will not do so. The effort 
to cause it to grasp the nipple worries and excites the mother, and in 
our experience this method is too unreliable and slow to compete 
with more prompt and efficient surgical measures. 

If the obstetrician fails to control hemorrhage from the uterus 
after labor by the methods described, he must recognize a condition 
of advanced toxemia, or possibly the development of syncytioma 
malignum. The writer has seen both of these conditions cause death 
within a few days after labor. Up to the present time we are not 
aware of any method of treatment which will save life under these 
conditions. Hysterectomy is scarcely possible with successful result 
in patients so depleted. 

Puerperal Hemorrhage from the Torn Cervix. — If persistent 
bright bleeding occurs after the uterus is empty, while the contractile 
portion of the uterus is firmly closed, the operator must suspect hem- 
orrhage from branches of the uterine artery. On inspection a con- 

25 



386 



OPERATIVE OBSTETRICS 



siderable tear of the cervix will be found, from which bright blood is 
slowly trickling If the operator is without suitable facilities for 
applying suture he must trust to the intra-uterine and vaginal tampon 
to check this bleeding In manv cases this will be successful. This 




Fig. 234. — Stitches applied in suturing a lacerated cervix (Kerr). 

method is, however, far inferior to the immediate control of the 
hemorrhage by suture. For this purpose, if possible, the two lips 
of the cervix should be grasped by the tenaculum forceps and drawn 
down to the '\n.ilva. The cervix should be carried strongly to the side 
opposite that which has been lacerated, the vulva opened by the 



THE CONTROL OF KHMOliKHACiH AKTKK LABOR 387 

fingers of an assistant or by a retractor, which will easily expose the 
site of bleeding. No. 2 chroniicizecl catgut should then be passed 
beneath the blecKling surfaces at the highest point of the laceration. 
The first stitch is often hard to apply, for the laceration may extend to 
the vaginal junction. The operator should persist, however, until he 
has satisfactorily inserted this stitch. It should immediately be tied 
and cut short. If this does not control the hemorrhage, other stitches 
should be inserted until the bleeding surfaces are brought firmly in 
apposition. 

Hemorrhage After Labor from Lacerations in the Posterior Seg- 
ment of the Pelvic Floor. — Lacerations in tliis portion of the birth- 
canal frequently extend so deeply that vessels are opened which bleed 
freely. As in the case of the cervix, such bleeding can be to some 
extent controlled b}' the tampon, but every effort should be made 
under aseptic precautions to immediately stop tliis bleeding by suture. 
To efficiently place such stitches the pelvic floor must be raised for 
inspection. This is accomphshed by passing the long finger of the 
gloved left hand into the rectum and raising the pelvic floor for the 
inspection of the operator. With a ciu'ved needle Xo. 2 chronii- 
cizecl catgut should be inserted deeply, the needle passing through the 
whole extent of the lacerated surfaces, and the peMc floor brought 
accurately together. Sutures should begin from the highest point of 
the laceration and be carried outward toward the perineum. If the 
tears be deep the stitches shotild be completely buried, and in severe 
cases it may be necessary to insert two layers of sutures. 

When the perineum is extensively torn the vessels in the skin sur- 
face may bleed as well as those in the weakest membrane of the 
vagina. Small cutaneous vessels may be controlled by the applica- 
tion of hemostats, which may be left until the operator can repair 
the pelvic floor first, and then turn his attention to the perineum. 
In complete laceration, small vessels in the rectal vaginal septum 
may recpire the application of hemostatic forceps and may be eflB- 
ciently closed by a separate ligature of fine catgtit Whenever possible, 
the control of hemorrhage in lacerations should be immediately 



388 



OPERATIVE OBSTETRICS 



followed by the complete closure of the tear. In extensive and un- 
usual tears of the pelvic floor and perineum the mucous membrane 
may be separated from the subjacent tissue and blood may accumu- 
late beneath the vaginal surface. In these cases the vaginal mucous 
membrane should be incised, the clotted blood turned out, the sur- 
face thoroughly irrigated with salt solution, and deep stitches placed 
to control bleeding. 




Fig. 235. — Thrombosis and hematoma of the vagina (Bumm). 

Hematoma of the labium may develop during and immediately 
after labor as the result of injury to the vessels beneath the mucous 
and cutaneous surface. If the tumor be small, and no other serious 
laceration be present, and if no opening exists between the tumor and 
the vagina or surface of the skin, the tumor need not be incised, but 
its further growth prevented by gauze pressure. If, however, the 
tumor increases rapidly in size and leaks into the vagina or upon 



THE COXTROL OF HEMORRHAGE AFTER I„\BOR 3S9 

the skin, a free incision should be made, the clot turned out, and 
burial sutures taken, or the cavity of the clot thoroughly packed with 
10 jx^r cent, iodoform gauze. \ erj' rarely in severe injuries to the 
genital canal hemorrliage occiu^ into the subi)eritoneal and submu- 
cous tissue above the vagina and around the cervix. Such hemor- 
rhage is usually controlled by the intra-uterine tampon, accompanied 
by the firm tamix)ning of the vagina with antiseptic gauze. 

Hemorrhoidal veins enlarge during pregnancy, may ]>e woimded 
during deliver}-, and may bleed freely. Such hemon-hage can be 
controlled by t^ing the vein at the point of bleeding or by passing 
a catgut ligature deeply beneath the vein and t^Tng it. 

Hemorrhage in the Anterior Segment of the Pelvic Floor Occur- 
ring After Labor. — If the anterior segment of the pehic floor ]ye exam- 
int-d LQ all cases of labor, in a considerable percentage, perhaps one- 
third, there will be found lacerations on one or ]x)th sides near the 
orifice of the urethra, occasionally as high as the clitoris, sufficiently 
deep to cause bleeding. 

In a case in the writer's experience in a primipara, such a lacera- 
tion was the only one which occurred during labor, and caused 
sufficient hemorrhage to reciuire immecUate suture. This condition 
can be diagnosricated by inspecting the parts and thoroughly spong- 
ing them with cotton or gauze six>nges dipped in salt solution or 1 
per cent, lysol. To stop such hemorrhage X*:-. 1 or 2 chromicized 
catgut should be passed with a fine needle completely around the 
bleeding surface. If the laceration be extensive it is weU to introduce 
a catheter into the bladder to avoid carrying the needle into the 
urethi-a. The ptmcture made by the needle wiU often bleed slight ly 
in these cases, but considerable hemorrhage is at once controlled, 
and the needle wound soon ceases to bleed. 

It is of the greatest importance in the avoidance of infection, and 
the securing of prompt recovery- from labor, that hemon-hage after 
labor be promptly controlle<I. Tliere is certainly no adequate reason 
why the puerperal woman should not have the benefit of the same 
methods of hemostasis commonly employed in other branches of 



390 OPERATIVE OBSTETRICS 

surgery. It may be urged that confinements are conducted under 
circumstances which make the surgical treatment of the parturient 
woman impossible. To this we reply that modern obstetric science 
is conducted upon surgical principles, and that one is not competent 
to practice modern obstetrics who does not have the facilities for 
surgical treatment and who is not competent to employ them. 

Bibliography of Hemorrhage Complicating Labor and the 

Puerperal State 

Ahlfeld: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 54, Heft 1, 

1905. 
Busse: Zentralblatt f. G^Tiakologie, Xo. 7, 1909. 
Davis: Progressive Medicine, p. 195, 190S. 
Edgar: American JouiTial of Obstetrics, December, 1908. 
Goth: Zentralblatt f. Gj-nakologie, No. 15, 1908. 
Henry: British Medical Jom'nal, June 8, 1907. 
Hense: Zentralblatt f. Gynakologie, Xo. 29, 1908. 
Herzfeld: Archiv f. Gynakologie, Band 82, 1907. 
Hohne: Zentralblatt f. Gynakologie, Xo. 10, 1909. 
Ihm: Inaug.-Diss., Heiclelbm'g, 1906. 
LePage : British Medical J^m-nal, Januaiy 26, 1907. 
Martin: Monatsschrift f. Gebtntshiilfe und Gynakologie, Band 23, Heft 

2, 1906. 
Mathar: Inaug.-Diss., Freiburg. 1906. 
Momburg: Zentralblatt f. Chirurgie, Xo. 23, 1908. 
Rielander: Zentralblatt f. Gynakologie, Xo. 28, 1909. 
Sigwart: Zentralblatt f. Gynakologie, Xo. 7, 1909; Berliner k. Wochen- 

schiTft, Xo. -13, 1909; Archiv f. Gynakologie, Band 89. 1909. 
Stowe: Surgery, G5Tiecolog%', and Obstetrics, June, 1907. 
Zickel: Zentralblatt f. G5nakologie, Xo. 34, 1908, and Xo. 15, 1909. 
Weber: Zentralblatt f. Gynakologie, Xo. 41, 1909. 
Westermark: Archiv f. Gynakologie, Band 89, 1909. 

PLACENTA PREVIA 
Hemorrhage before, during, and after labor may arise from the 
abnormal situation of the placenta or premature separation of the 
normally implanted after-birth. 

For purposes of operation, placenta prse^-ia may be divided into 
central or complete and partial or incomplete. In the former, the 
spontaneous recovery of the patient cannot be expected, as hemor- 



PLACENTA PILEVIA 391 

rhage cannot cease until the uterus is emi^tied, and labor cannot go 
on without separating the placenta and producing hemorrhage. 

The older methods of treatment consisted in tamponing or plugging 
the cervix, in the hope of making sufficient compression upon the 
placenta to check bleeding until delivery could be accomplished. The 
application of cotton tampons tightly packed and, later, the use of 
antiseptic gauze as a tampon have been extensively practised and 
recommended. The introduction of Bossi's dilator led to the use of 
tliis instrument for the rapid dilation of the cervix. The Braxton- 
Hicks method, which consists in grasping a foot of the fetus and bring- 
ing down the leg and breech as a tampon, has long been used. 

Each of these methods left much to be desired. In the Braxton- 
Hicks procedure the effort to grasp the foot of the fetus led to increased 
separation of the placenta, to renewed bleeding, and sacrificed the 
life of the child. Experience has shown that the use of the tampon, 
even under antiseptic precautions, has been followed by considerable 
hemorrhage and infection, and that the cliild has often been lost. 
These methods of treatment, however, are still extensively practised 
in private houses by general practitioners, and are often the best 
method available for a given case. 

Of late years the frequent practice of delivery by abdominal section 
has proved successful in some cases of central placenta prsevia. The 
application of intraovidar pressure, by piercing the placenta and 
introducing an elastic bag through its substance into the sac of the 
ovum, has also given good results. 

Pfannenstiel (Monatsschrift f . Geburtshulfe und Gynakologie, Band 
29, Heft 3, 1909) advises that the bag be grasped with suitable forceps 
and introduced through a speculum, the cervix being firmly held at 
the same time. The forceps for applying the bag should be long 
enough to reach to the interior of the ovular sac, and should have a 
pelvic curve. The placenta must be pierced by the bag in the grasp 
of the forceps, and the thinnest portion of the placenta available 
should be sought for this purpose; 500 c.cm. of sterile salt solution 
should then be injected and the bag fully distended within the ovular 



392 OPERATIVE OBSTETRICS 

sac and above the placenta. It is estimated that a pressure of 1 kilo 
can thus be exeited. Every ehon should be made to secure the spon- 
taneous expulsion of the bag. when the operator can proceed to ter- 
minate labor, usually by version and extraction. 

The results of the so-called conservative methods of treating 
placenta prtevia in recent years may be estimated from Xovak's 
extensive rcAdew of the subject ]\Ionatsschrift f. Gebunshulfe und 
Gynakologie, Band 30, Heft 2, 1909). From the simple procedure of 
rupturing the membranes in panial placenta prievia. and allowing 
uterine contractions to compress the placenta, he finds 163 cases 
repoited liy diherfut authors, with no maternal monality. The 
monality among the cliildren at birth was 25, or 15.3 per cent. Tliis 
represents the simplest forms of placenta prievia an;! the simplest 
available treatment which is sufficient for the mother, biu attend^;! 
by considerable fetal moitality. In ad'Iition xo the cliiLIren still- 
born a considerable numl^er of those living at biith die >oon afterward 
from weakness. 

Allien version and extraction were practised he foim*:! in 878 cases 
reported by different atithors a maternal mortality of 8.S per cent, 
and a fetal mortahty of 71. S per cent. 

Weischer. in Olshausen's clinic in Berlin Zeitschrift f. Gebuitshulfe 
und G}makologie. Band 67, Heft 2. 1910 . in combined version had a 
maternal mortality of 7.4 per cent, and a fetal mortality of 74.1 per 
cent. Other authors report shghtly difterent mortality rates for this 
method of treatment, but the general result is much the same. 

By the use of dilating bags AVeischer's maternal mortality was 
8.5 per cent. an;l the fetal mortality 46. S per cent. 

Hammerschlag, Hannes, and Burger-Graf had a maternal mortality 
of 5.8 per cent.; Zinomermann. 6 per cent.: Hoist. 12.5 per cent., and 
Sigwart, in 33 eases treated by the use of bags, had no maternal mor- 
tality. 

In fetal mortality. Thies had 14 per cent.: Diihrssen. 16.6 per 
cent.: Freund. 20 per cent.: Hannes, 30 per cent.: Keetman, 50 per 
cent.: Zimmermann, 62 per cent.: Hoist, from 60 to (5d per cent. 



I'LACENTA I'K.KVIA 393 

Weischer ascrihos thi^ mati^rnal mortality in his cases to the fact 
that patients were adniittal to the hospital much prostrated by loss 
of blood, and tiiat the treatment wliich endc\l labor produccnl additional 
hemorrhage sufficient to turn the scale. He concludes that the use 
of bags should be practisal only when the child is living, at full term, 
and in fairly gooil condition. 

Novak has collectal 2081 cases in the literature reported by 
dilYerent authors, in which various methods of treatment, exclusive 
of Cesarean section, were practised. The maternal mortality of this 
series is 8.65 per cent.; the fetal mortality. 56.72 per cent. 

In view of the high maternal mortalit}- from the use of bags, it is 
e^ident that their use is justifiable only in cases where the bag can 
be introduced with the least possible disturbance to the placenta. 
and without increasing materially the hemorrhage wliich threatens 
the mother's life. Their use is indicated in partial placenta praevia 
where the ruptm-e of the meml^ranes is not followed b}' prompt uterine 
action and by sufficient dilation to bring the presenting part firmly 
against the placenta. In central placenta pnevia their use can be 
successful only in those exceptional cases where the placenta is so 
thin at some available point that it can be rea<lily pierced by the 
bag in the grasp of the forceps without producing much separation or 
free hemorrhage. 

The high mortality of placenta pnevia treatetl by other methods 
has led to the resort to Cesarean section. Early experience seemed 
to indicate that no essential gain would be ma^le by section. 

Mattoli's remarkable ca.se (Arch. ital. di ost. e. gin.. Is99\ a suc- 
cessful delivery by Cesarean section of an anemic woman with central 
placenta prievia, is reporte<l. The operation was performed in a 
dirty kitchen and was followe<I by undisturbed recovery, indicating 
the possibilities of the operation. 

Bumm ( Zentralblatt f. Gynakologie, Xo. 52, 1902) reported a case 
of central placenta prtevia successfully treated by vaginal section. 
Buttner, Drxlerlein, and Xijhofi' reported successful cases treated by 
vaginal section. Kronig and Sellheim, in 1907, drew attention to 



394 OPERATIVE OBSTETRICS 

the value of cervical section, while Zweifel declared against it. In 
cases of rigid cervix Henkel would perform cervical section in the 
interests of the mother. Sellheim, by extraperitoneal section in 8 cases, 
had the recovery of 8 mothers and 8 children. Baisch, from Doder- 
lein's clinic, in 40 cases of vaginal Cesarean section had the recovery 
of all the mothers, and in 22 children living before the operation 19 
were born living. Among this series of vaginal sections were 10 done 
for placenta prsevia. 

Thies (Monatsschrift f. Geburtshiilfe und Gynakologie, p. 270, 1909) 
reports from the Charite clinic in Berlin 178 cases of placenta prsevia 
treated by different methods, with 3 per cent, maternal mortality. 
Among these cases 11 were treated by the use of bags, with the birth 
of 11 living children. Many of these cases were polyclinic cases, in 
which the use of the bag was successful in the houses of patients. 

Gussakow, in Fenomenow's clinic in St. Petersburg, believes that 
all methods are dangerous which produce uterine contractions before 
the rupture of the membranes. The use of the tampon is not indicated 
for this reason, and because it predisposes to infection. In partial 
placenta prsevia the rupture of the membranes often checks the 
hemorrhage. In addition to this the use of the dilating bag is indicated. 

In central placenta prsevia, if the life of the child is held valuable. 
Cesarean section is indicated. 

Hauch, from the clinic in Copenhagen (Monatsschrift f. Geburts- 
hiilfe und Gynakologie, Band 31, Heft 5, 1910), believes that the use 
of the bag should lessen fetal mortality without greatly increasing 
the maternal mortality. 

Kupferberg (Monatsschrift f. Geburtshiilfe und Gynakologie, 
Band 31, Heft 5, 1910), in using the bag for dilating purposes- in 
placenta prsevia, produced an extensive tear in the cervix, extending 
above the vaginal junction, followed by alarming hemorrhage. 

Pankow, in Kronig's clinic in Freiberg (Zeitschrift f. Geburtshiilfe 
und Gynakologie, Band 64, Heft 2, 1909), reports 8 successful cases of 
suprasymphyseal section for placenta prsevia. 

Doderlein (Archiv. f. Geburtshiilfe und Gynakologie, Band 92, 



PLACENTA PU.EVIA 395 

Heft 1, 1910) writes a critical paper drawing attention to the advan- 
tages of the suprasyniphyseal section. 

Sippel (Monatsschrift f. Gebui-tshiilfe und Gynakologie, Band 33, 
Heft 3, 1911) reports a case of placenta prsevia in which profuse hemor- 
rhage was checked by bringing down the fetus through traction upon 
the leg. As tliis did not control the bleeding, abdominal Cesarean 
section was performed, followed by supravaginal amputation of the 
uterus, with the patient's recovery. 

Novak (Monatsschrift f. Geburtshiilfe und Gynakologie, Band 30, 
Heft 4, 1909) contributes a critical paper in which he reviews the sta- 
tistics of various European clinics and the results by the various 
methods of treatment of placenta prsevia. He admits it is possible 
in cases where there is some stricture of the uterus to improve the 
maternal results by Cesarean section. The results for the fetus by 
other methods of treatment are so disastrous that where value is 
placed upon fetal life, Cesarean section is indicated. He makes the 
significant observation that the objections to Cesarean section lie in 
the fact that the patient usually comes under the observation of the 
operator when profoundly anemic and infected by the careless use of 
the tampon. He believes that the classic Cesarean section will prove 
the best method of delivery. 

An analysis of these statistics and the writer's experience lead 
him to believe that cases of placenta prsevia should be divided into 
two classes: the first are those in which the placenta does not com- 
pletely cover the os ; or in which the greater portion of the placenta 
is upon the lateral wall of the uterus, and but one lobe covers the 
OS, leaving a thin portion between the greater and the lesser pla- 
cental mass. In these two classes of cases rupture of the membranes, 
or rupture of the thinned portion of the placenta, and stimulation of 
uterine contractions will usually suffice to check hemorrhage and 
make delivery reasonably safe for the mother. The fetal mortality 
under such conditions must be high, for labor is delayed and there 
is danger of infection in the fetal sac. Whether pressure be applied 
without the sac of the ovum or within the sac of the ovum, it 



396 OPEEATIVE OBSTETKICS 

must be done in such a manner as to disturb the placenta as little as 
possible, and not to increase the hemorrhage. If the bag can be 
introduced under these conditions, it will shorten labor and should 
lessen fetal mortality some^Yhat. These methods should be preferred 
to the Braxton-Hicks method or the use of the tampon, because the 
latter disturbs the placenta more, excites more hemorrhage, and causes 
greater fetal mortality. These methods, however, are available in 
private houses, and may often be successfully used by inexperienced 
operators. 

In cases where the greater placental mass is directly over the 
internal os, it is of the utmost importance that as little disturbance as 
possible by examination or treatment should be practised. The first 
hemorrhage is usually so characteristic that a diagnosis may often be 
made by this, and confirmed by a very cautious vaginal examination. 
With mother and child in good condition, abdominal classic Cesarean 
section should be practised as speedily as possible. This should not 
be followed by a greater maternal mortality than the most favorable 
results in all cases of placenta prsevia, namely, Thies' statistics of 
3 per cent. The fetal mortality should be reduced gi'eatly by such a 
procedure. 

We have had the opportunity of putting this reasoning in practice 
in 3 suitable cases in which we practised abdominal Cesarean section. 
The three mothers recovered, and two of the three children, one 
being premature, survived but a short time. 

There is, we believe, some analogy between placenta prsevia and 
ectopic gestation. In each the cardinal dangers are from hemorrhage 
and infection, occasioned by the abnormal attachment of the o-\aim. 
In each the only reliable method of treatment consists in operation. 
In placenta prsevia, in cases at full term, with mother and cliild in 
good condition, the life of the fetus cannot be entirely disregarded. 

Bibliography of Placenta Previa 
Baisch: Miinchener med. Wochenschrift, No. 3, 1909. 
Calzolari: Annaii di Ostetricia e ginecologia, No. 8, 1909. 
Doderlein: Archiv f. G3makologie, Band 92, Heft 1, 1910. 



FHEMATURE DETACHMENT OF NORMALLY LMl'LANTED i'LACENTA 397 

Fn': American Journal of Obstetrics, January. 1909. 

Filth: Zentralbiatt f. Gynakologie, Xo. 5, 1911. 

Gussakow: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 32, 

Heft 3, 1910. 
Hannes: Zentralbiatt f. Gynakologie, Xo. 3, 1909. 
Hauch: Monatsschrift f. Geburtshulfe und Gynakologie, Band 31, Heft 

5, 1910. 
Jewett: American Journal of Obstetrics, June, 1909. 
Kronig: Zentralbiatt f. Gynakologie, X'os. 15 and 34, 1909; Monats- 
schrift f. Geburtshulfe und Gynakologie, Band 29, Heft 1, 1909. 
Moncalvi: Annali di Ostetricia e Ginecologia, X^o. 11, 1909. 
X'ewell: American Journal of Obstetrics, June, 1909. 
X'ovak: Monatsschrift f. Geburtshulfe und Gynakologie, Band 30, Heft 

3 und 4. 1909. 
Glow: Zentralbiatt f. Gynakologie. X^. 13, 1910. 
Pankow: Zeitschrift f. Geburtshulfe mid Gynakologie, Band 64, Heft 

2, 1909. 
Pfannenstiel : Monatsschrift f. Geburtshiilfe und Gynakologie, Band 29, 

Heft 3, 1909. 
Richter: Zentralbiatt f. Gynakologie, X'o. 22, 1909. 
Runge: Zentralbiatt f. Gynakologie, X^. 31, 1909. 
Sigwart: Zentralbiatt f. Gynakologie, Xo. 28, 1910. 
Sippel: Monatsschrift f. Geburtshulfe und Gynakologie, Band 33, Heft 

3, 1909. 
Thies: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 29, Heft 

3, 1909. 
"Weischer: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 67, Heft 

2, 1910. 
Zimmermann: Zentralbiatt f. Gynakologie, X'o. 10, 1909. 

PREMATURE DETACHMENT OF NORMALLY IMPLANTED PLACENTA 
Tliis accident is considered by many as more common than placenta 
prsevia. It is frequently more difficult to recognize, as there may be 
no apparent hemorrhage, and attention may not be called to the 
patient's condition until pain and syncope indicate the gTa^'ityof the 
accident. 

Goodell, in 1869, collected 106 cases; Holmes, in 1901, added 200; 
Colclough, in 1902, reported 82 cases, and Goldstine (Surgery, Gyne- 
cology and Obstetrics, February, 1910) adds 98. 

This accident probably occurs about once in 250 la])ors. SHght 



398 OPERATIVE OBSTETRICS 

separation is frequently not noticed , and may be inferred when, after 
the expulsion of the child, dark, clotted blood is expelled with the 
placenta. In most cases the hemorrhage makes its way through the 
vagina, while in a small proportion clotted blood remains within the 
uterus, greatly distending the uterus and separating the placenta until 
fetal death occurs and the patient is brought into a dangerous condi- 
tion through syncope. 

In 488 reported cases, 365 had external or mixed hemorrhage, and 
in 123 the bleeding was concealed. The symptoms are those of 
developing anemia, with pain and tension of the uterine muscle, 
making it impossible to accurately hear the fetal heart. Should 
hemorrhage continue, and the patient pass into a grave condition, 
the tone of the uterine muscle will be lost and it will become a flaccid 
tumor, distended with blood-clot. 

The maternal mortality is stated by Goodell as 50.9 per cent.; the 
fetal mortality as 94.4 per cent. Holmes, maternal mortality, 32.2 
per cent. ; fetal mortality, 85.8 per cent. DeLee, maternal mortality, 
50 per cent.; fetal mortality, 90 per cent. Herzfeld, maternal mortal- 
ity, 29 per cent. ; fetal mortality, 82.79 per cent. Colclough, maternal 
mortality, 9 per cent. ; fetal mortality, 90 per cent. 

Reports of the Rotunda Hospital, Tweedy, master, maternal 
mortality, 10 per cent. ; fetal mortality, 95 per cent. 

Should the patient escape death during delivery, postpartum 
hemorrhage is often severe and may turn the scale. Rupture of the 
uterus is not rare in these cases. 

The older method of treatment consists in rupturing the mem- 
branes and employing the tampon until the cervix is sufficiently 
softened to make rapid dilation possible, followed by version, and 
later by spontaneous birth or extraction. Statistics show that there 
is a marked difference in the results when delay is practised after the 
rupture of the membranes, or when the operator proceeds to im- 
mediate extraction. Immediate operation is dangerous in these 
cases, because the patient is more or less weakened by hemorrhage, 
the uterus is atonic, and will not contract promptly, the patient is in 



PUEMATLKE DETACHMEXT OF NORMALLY IMl'LAXTKD I'LACEXTA 399 

no condition for general anesthes^ia, and rapid dilation of the eervix is 
accompanied by serious laceration. Post])artuni hemorrhage after 
immaliate delivery is often severe. The Rotunda method, advocated 
and practised by Colclough, Smyley, and Tweedy, consists in firmly 
tamponing the vagina, having pre^■iously, if possible, rui)tured the 
membranes. The abdomen is tlien tightly bandaged from above 
downward, the bladder emptied by catheter, and the patient given 
sufficient opium to relieve pain and restlessness. The tampon is 
left, if possible, until uterine contractions expel it. if within twenty- 
four hours. Should this not occur, it is removeil in twenty-four hours 
and replaced. Better results are sometimes obtained when the mem- 
branes are not ruptured, although the method is successful after the 
anmiotic liquid has escaped. 

The most recent method of applying this treatment consists in 
using tampons of sterilized cotton-wool moistened with salt solution 
or weak bichlorid solution. AVith the lithotomy position, using the 
fingers of one hand as a speculum, the cotton pledgets, scjueezed almost 
dry, are introduced in such a manner as to form a ring around the 
cervix and to pack the entire vagina as tightly as possible. A large 
piece of gauze is placed externally, and the abdominal and perineal 
bandages are applied. The tampon is removed should the pains 
become vigorous, should the tampon iDulge when hemorrhage 
appears externally, or when the patient has an attack of s}m- 
cope. The bladder should be freciuently emptied by catheter. Out 
of 69 cases reported by Goldstine, hemorrhage was thus controlled 
in 66. 

In view of the high maternal and fetal mortality following this 
accident, other methods of treatment than the tampon have been 
employed. 

SigA;\-art (Zentralblatt f. Gynakologie, No. 7, 1909; Archiv f. Gyn- 
akologie, Band 89, 1909), Holme (Zentralblatt f. GjTiakologie, Xo. 10, 
1909), Krdning (Deutsche med. Wochenschrift, No. 46, 1909), and 
Weber (Zentrall^latt f. G}Tiakologie, Xo. 41, 1909) have tried the ap- 
plication of ^lomburg's bandage in controlling placental hemorrhage 



400 OPERATIVE OBSTETRICS 

during labor. Their experience shows that this method greatly 
lessens or controls such hemorrhage, but that it cannot be continued 
for a long time. In 2 of Sigwart's cases, which resulted fatally, autopsy 
showed that the abdominal viscera were not injured by the use of the 
bandage. 

The good results claimed for section of the lower portion of the 
uterus as a means of emptying the uterus promptly, without dangerous 
trauma, have drawn attention to the value of these operations for 
placental separation. Diihrssen and his followers have endeavored 
to apply this method, and claim for it a considerable success. The 
advocates of suprasymphyseal section advise its trial in patients in 
good condition. The merits of these operations for placental separa- 
tion are not yet accurately known, nor is it positively ascertained that 
vaginal or suprasymphyseal section will giver better results than the 
classic abdominal Cesarean section. 

In the present state of our knowledge we can summarize the treat- 
ment of placental separation when placenta prsevia is not present 
as follows: 

In patients in private houses, and not under the care of an obstetric 
surgeon the use of the tampon by the Rotunda method, with or with- 
out rupture of the membranes, will control the hemorrhage and give 
a reasonable chance for the mother. The survival of the child will 
be the exception and not the rule. 

In cases where a diagnosis is made early, with mother and child in. 
good condition, delivery by section, with hospital advantages, will give 
the mother the best chance for recovery, with a possible chance for the 
child. 

Section should not be undertaken upon patients weakened by exces- 
sive hemorrhage and in generally bad condition. In performing the 
major operations general anesthesia should be avoided, and anes- 
thesia by spinal injection, if possible, should be employed. 

To be avoided as especially dangerous are rapid dilation and extrac- 
tion through the vagina. Such cannot be done without general 
anesthesia; there is always with this treatment considerable hemor- 



IMMEDIATE REPAIR OF LACERAT!"V- ay THE GENITAL TRACT 401 

rhage during extraction: dangerous iaccratioiLs not infrer|uently occur; 
and postpartum hemorrhage is conunon and often fatal. 

In the \*Titer"s experience, no cases ha^e com? under obser\"ation 
in suflSciently good contlition to justify him in performing a major 
operation. The use of the tampon in cases where tUlation had not 
begun has been reasonably satisfactor\-. Some of these cases do not 
come to the attention of the operator until labor has abready b^un, 
the cenix has ])een obliterated, and partial dilation is possible. 
I'n<ier these circumstances, if the membranes have not been niptureil, 
this should immeliately be done and the uterus stimulated to contract 
by tonic doses of strychnin. When the uterus expels its contents, 
irrigation with hot sterile salt solution, with compression of the 
aorta through the uterine wall. with, the hand within the womb, 
or externally by Momburg's method, will temporarily control the 
hemorrhage. The uterus shoukl then be firmly packed antl the 
vagina tamponed, and intravenous saline transfusion practised. 

The writer has been successful by this method in apparently 
desperate cases. 

BiBLIOGRAPHT OF PrFV T ZZ DETACmiEN-r OF XORM.\IXY 

iMPLAXTiiD Placenta 
Colclough: Journal of Obstetrics and Gynecology, 1902. 
De Lee : American Journal of Obstetrics, 1909. 
E<^lgar: Text-Book of Obstetrics. 

Engstrom : Reports of Helsingfois Clinic. Berlin. 190S. 
Cioldstine: Smger>-. GA-necologj-, and Obstetrics^ February, 1910. 
CioodeU : American Journal of Obstetrics, vol. 2. 1S70. 
Herzfeld: Archiv f. Gynakologiej vol. S2. p. 304. 1907. 
Holmes: American .Journal of Obstetrics, vol. 44, 1901. 
Tweedy: Rotunda Reports. 1905-1909. 

THE IMMKI)L\TE REPAIR OF LACERATIONS OF THE GENITAL TR.\CT 
In parturition and in the artificial empt>Tng of the uterus, as in 
therapeutic abortion for toxemia, lacerations of varying degree are 
not uncommon. It is impossible to estimate their frequency because 
it is difficuh to obtain a precise statement as to what constitutes a 
laceration. A slight woimd of the mucous membrane extending 

26 



402 OPERATIVE OBSTETRICS 

through the fourchette may not cause hemorrhage an(]. under favor- 
able circumstances, may be left to heal without suture, but even this 
invites infection, and under aseptic precautions may be close<l to 
advantage. The closure of lacerations of the genital tract compli- 
cating labor may be immediate, intermediate, or late. By this we 
mean that the obstetrician may repair lacerations within a few 
hours after the birth of the child, or he may elect to delay from five 
to seven days after labor, or he niay prefer to allow the patient to 
recover from childbiith. and seA'eral weeks or months after she has 
become convalescent, repair lacerations by a plastic operation. 

The Immediate Repair of the Cervix. — At varying periods since the 
introduction of antiseptic precautions in obstetric practice, efforts 
have been made to immediately close lacerations of the cerAdx. In 
some instances these methods liaAT been successfid: in others the 
effort has been followed by the development of septic infection and 
by bad results. The writer was first led to close immediately the 
torn cerA'ix in cases v\diere hemorrhage called for the immediate appli- 
cation of sutures by the needle. Observing that in these cases hemor- 
rhage was not only checked, but the cervix healed without complica- 
tions, he was led to extend the application of sutures to the torn cervix 
where hemorrhage was absent. AVe have followed this procedure for 
some time in priA^ate. hospital, and out-patient practice, with the 
result that SO per cent, of these cases Iv^xe had good and primary 
union. 10 per cent. Iieat had partial union, and 10 per cent, had no 
apparent result from the application of sutures. AVe have been unable 
to trace infection or other comphcations as the result of this eftoit 
to repair the cer^dx. AVe do not. howeA'er. belieA'e that the iimnediate 
repair of the ceiwix should be undertaken except under antiseptic 
precautions and by those who have experience in obstetric surgery. 
The advantages to be gained by this method are better iuA-olution. a 
more prompt recoA'ery from childl^irth. and the aA'oidance of infec- 
tion. In many of these cases the uterus has been tamponed to pre- 
vent or control hemorrhage, and the suture of the cer^dx has assisted 
in maintaining pressure upon the uterine atsscIs. while the presence 



IMMKDIATIO UEPAlll OF LACERATIONS OF THE CiKNlTAL TKACT 403 

of the gauze within the uterus has in no way interfered with the elosure 
of the torn cervix. 

The technic of this procedure is essentially that described in 
suturing the cervix to control hemorrhage. With the patient in the 



/ ; 





Fig. 236. — Closing a recent laceration in the left side of the cervix (Nagel). 

dorsal position, and with a suitable light, the lips of the cervix are 
grasped by tenaculum forceps and drawn downward and the vulva 
retracted until the operator can examine the tear visually ; or, if this 



404 



OPERATIVE OBSTETRICS 



is impossible, until he can palpate it accurately with the thumb and 
finger. Especial care should be taken in introducing the highest,, or 
first stitch. This should include entirely the torn tissue, and after it 
has been tied the long ends of the catgut may be left to serve as a 
gTiide for the succeeding stitches. The lacerations should be closed 
from above downward , leading a small surface at the external os 
without suture. This will heal by the involution of the tissues and 
there will be no possible interference with the discharge of the lochia. 
Usually the greater tear is upon the left side, but if both sides are 





Fig. 237. Fig. 238. 

Figs. 237 and 2.38. — Closure of deep laceration of perineum and pelvic floor: C, C, 
Posterior commissure i^Bumm). 

lacerated, both should be closed. Twenty-day catgut is usually 
employed, and we have seen no trouble follow from the retention of 
sutures after the puerperal period. 

The Immediate Repair of Lacerations of the Posterior Segment 
of the Pelvic Floor and Perineum. — To properly perform tliis opera- 
tion the obstetrician must keep in mind the fact that so far as the 
patient's future health is concerned the pelvic floor and the sphincter 
muscle of the bowel are of primary importance. The skin perineum 
is of secondary importance. In lacerations of considerable extent, 
although not complete, the tear reaches to the sphincter muscle and 



IMMEDIATIO KKI'AIR OF LACERATIONS OF THE GENITAL TRACT 40.3 



r^^^ 





Fig. 239. — Complete recent laceration of pelvic floor; first step in repair, suturing 

the bowel (Nagel). 



may wound some of its fibers. Unless this be kept in mind, and the 
muscle accurately closed, the patient will suffer as a consequence. 
To accurately close such lacerations the patient should be upon 



406 



OPERATIVE OBSTETRICS 



her back on the edge of a high bed or table, the lower limbs flexed 
upon the trunk and rotated slightly outward. As the hemorrhage 
which follows labor may be sufficient to obscure the field of operation, 
the vagina should be sponged out with sterile gauze and a moderate 
packing of sterile gauze placed over the cervix and in the posterior 
vaginal vault above the point of laceration. If the operator cannot 
clearly distinguish the highest point of the tear, he should intro- 
duce the longest finger of the gloved left hand, palm upward, into 
the rectum and raise the pelvic floor for inspection. Beginning 




Fig. 240. — Complete recent laceration of the pelvic floor; second step, the 
rectum having been closed, the pelvic floor and vaginal wall are sutured: V, vag- 
inal tissue; R, rectal tissue (Nagel). 

at the highest point of the tear, stitches of No. 2 chromicized 
catgut should be inserted with a curved needle, encircling com- 
pletely the lacerated tissues. The highest point of the tear 
should receive especial consideration, and the stitches should be 
passed deeply. In extensive lacerations the tear may extend 
deeply into the pelvic tissues, involving the uterosacral ligaments. 
It will be greatly to the patient's advantage if the operator can succeed 
in closing such lacerations through the vagina. A^Tiere they do not 
heal, the cervix tends to prolapse forward and retroversion is readily 



IMMEDIATE HETAIH OF LACERATIONS OK THE GENITAL TKACT 407 

established. Lacerations of the [)elvic floor should bo siitunHl from 
above downward to within > inch of the junction of the; vaginal 
mucous membrane with the skin perineum. The two sulci of the 
})elvic floor should be thoroughly examined and each carefully 
closed. Care should be taken not to extend the sutures in the pelvic 
floor on to the skin perineum. If this be done, the pelvic floor will be 
pulled downward, the posterior vaginal wall will be shortened, and a 
tendency to rectocele and retroversion will be established. 

When the pelvic floor has been sutured the operator should turn 
his attention to the sphincter muscle. If its substance has been in- 
jured the fibers should be brought together by stitches of No. 1 
chromicized catgut completely buried. The sheath of the muscle 
should be closed separately and accurately. If the tear in the pelvic 
floor has been a deep one, at its deepest point buried sutures may be 
introduced and the superficial tissues closed above them. 

Immediate Closure of the Perineum. — After the pelvic floor and 
sphincter muscle have received attention, the operator should begin 
at the lowest point of the perineal laceration. If the perineal tear be 
very deep, and especially if it be oozing, several buried sutures of cat- 
gut should be inserted. The skin edges should be brought together 
by interrupted stitches of sikworm gut, beginning at the point nearest 
the anus. Care should be taken to close this point accurately to pre- 
vent fecal matter from getting into the wound. The perineum is to be 
closed up to the point where the mucous membrane of the vagina 
meets the cutaneous surface. At this point the operator will have an 
opportunity to observe whether he has completely closed the pelvic 
floor, or whether he shoukl insert additional stitches at the lower end 
of the pelvic-floor laceration. Usually it will be found best to close 
the skin perineum completely, and should the two lines of suture not 
meet, to insert from above one or two catgut stitches, completing 
the closure. If the laceration has been properly treated, the pelvic 
floor will be carried upward and backward, and when the repair is 
complete, the stitches in the pelvic floor will not be visible, and the 
Jumen of the ^'agina will be restored to something like its original 



40S 



OPERATIVE OBSTETEIC: 



proportions. If the sutures have been improperly placed, the poste- 
rior waU of the vagina will be di-aggecl downward, the perineum will 
be shortened, and the orifice of the vagina considerably enlarged. 

Some prefer to use chromicized catgut for closing the skin perineum. 
As these stitches will be constantly moistened with lochial discharge. 



Upper end of tear 



Posterior commb- 
sure 



Tear in bcwel 



Antericr vasinal wall 




Posterior vaginal 
wall 



Poeterior eommis- 
snre 



Tern fibers of 

sphrncter 
Tear in mucous 

membrane of 

bowel 



Fig. 241. — Complete laeeration of perineum CBumm). 



and must be repeatedly cleansed by Irrigation . it is more prudent 
to employ silkworm catgut upon cutaneous sm-faces. These stitches 
may be left long and tied together and carried to one side of the vulva, 
or may he cut short, as the operator may elect. 

The Immediate Closure of Complete Lacerations of the Pelvic 
Floor and Perineum. — In these cases the operator should carefully 
identify tht^ mucous membrane of the recttun and the sphincter muscle. 
These should be brought together fii*st, bednning at the highest point 



IMMKDlATi: KKr.UU OF LACEliATlOXS OP^ THE CKXITAL TllACT 409 

of the rectal tear antl using a continuous suture of Xo. 1 chronii- 
eizeil catgut for the rectal surface. The sphincter should he ])roug]it 




Fig. 242. 



Fig. 243. 



Figs. 242 and 243. — Closure of tears in lateral sulci in complete laceration of peri- 
neum or edges of wound at anus (A, A) : C. C, Posterior commissure (Bimim). 

together with interrupted buried sutures, as akeady described. The 
operator should then turn his attention to the peMc floor, inserting 
buried catgut sutures wherever reciuired to build the tissue up firmly 




Fig. 244. — Closing the rectal wall in complete laceration of the perineum. A, A, 
Torn bowel at anus; C, C, Posterior commissure (Bumm). 

from the bottom. The pelvic floor and perineum may then be closed 
in the manner alreadv described. 



410 OPERATIVE OBSTETRICS 

Immediate Closure of Lacerations of the Anterior Segment of the 
Pelvic Floor. — These may vary from slight lacerations requiring but 
a single stitch to deep lacerations at the side of the urethra, which 
may even include the urethra or, in some cases, the base of the bladder. 
In severe cases a catheter or sound should be placed in the urethra, 
to identify it, before suture is begun. Buried catgut sutures should 
be placed at the bottom of such tears and the surfaces brought accu- 
rately together by interrupted suture. If the urethra has been torn 
the wound should be closed with fine catgut, and the tissues over it 
separately brought together, and a permanent soft catheter placed in 
the bladder for drainage. If tears in the anterior segment open into 
the peritoneal cavity, as is sometimes the case after pubiotomy or 





Fig. 245. Fig. 246. 

Figs. 245 and 246. — Closure of superficial laceration of perineum: C, C, Posterior 
commissure (Bumm). 

lacerations following the use of Bossi's dilator, a strand of gauze 
may be carried through the laceration and left for several days as a 
drain. The greater part of the laceration may then be closed, leav- 
ing sufficient room for the extraction of the gauze. Deep tears in the 
vicinity of the clitoris may be accompanied by free bleeding. In 
these cases buried sutures will control the bleeding, while the edges 
should be accurately approximated above the buried sutures. 

The Closure of Episiotomy Wounds. — After episiotomy a diamond- 
or lozenge-shaped surface remains for suture, the upper extremity 
of which is upon the lateral wall of the vagina, the lower extremity 
extending downward and outward through the skin surface of the 
labium and pelvic floor. Two lines of suture at right angles to each 



IMMEDIATE KEPAIR OF LACERATION'S OF THE GENITAL TRACT 411 

other are necessary to close these wounds. As such are frecjuently 
of considerable clei)th, a line of buried sutures should hrst be inserted 
and the edges brought accurat(dy together above it. 

The Closure of Unusual Tears of the Perineum. — In eases where the 
mucous membrane of the vagina has been stripped upward from the 
perineum it is necc^ssary to insert a circular row of stitchers, restoring 
the parts to their original condition. If the ju'esenting part has made 



Urethra 



Anterior vaginal wall 



Posterior vaginal wall 



Posterior commissure 




L'pper end of wound 



Lower end 



Fi^. 241 



-Closure of episiotomy wound iBunim). 



its way through the perineum, leaving the lower portion of the pelvic 
floor intact, the uninju ed portion should be laid open in the median 
line, and the tear converted into one complete laceration. This 
should then be brought accurately together from the bottom up- 
ward. 

Complications Following the Immediate Repair of Lacerations in 
the Pelvic Floor and Perineum. — The improper application of sutures 
in these wounds may be followed by dragging down of the posterior 



412 OPERATIVE OBSTETRICS 

wall of the vagina, shortening of the vaginal wall, shortening of the 
perineum, woimds of the urethra, imperfect closure of deep tears, 
lea^TQg pockets for the accumulation of blood and lochial discharge, 
and extensive closm^e of torn surfaces, partially occluding the vagina 
and favoring the retention of locliia. 

In the experience of the writer, two medical students on one oc- 
casion sewed together the greater part of the M.ilva in an effort to 
close a recent laceration. There is probably no operation of surgery 
whose proper performance is followed by more satisfactory' results 
and whose inacciu'ate emplo}TQent causes more distress and suffering. 
The common error consists in drawing the sutures too tightly in 
tying The tissues may swell somewhat for a day or two, although 
normal swelling rapidly decreases after labor. If the stitches are 
drawn too tightly the sutures ^dll cut through and the wound 
win gape asunder. In an effort made to repair lacerations too com- 
pletely the patient may be left in such a condition that in a subse- 
quent labor extensive laceration may be inevitable. Judgment and 
experience are required to close accurately the essential portions of 
the biith-canal, thus securing for the patient permanent conva- 
lescence. 

Accidents and Complications Following the Closing of Lacera- 
tions in the Birth-canal. — Infection m the stitches may develop 
within a day or two after their insertion. The tissues about the stitch 
become red and swoUen, and pus gradually oozes near the stitch upon 
pressiu-e. Stitches drawn too tightly through the skin surface espe- 
cially will cause considerable pain and distress. \\ hen the stitches 
become infecte<:l they should be immediately removed, the tissues 
allowed to gape open freely, and irrigated with dilute antiseptic 
solution. If infected stitches are not removed, the infection may 
burrow beneath the submucous and connective tissues and a deep- 
seated abscess mav result. 



INTERMEDIATE HElWIli OF LACEKATIOXS OV THi; (iEMTAL TI(A( T 413 
BiBLUHJHAl'HV OF THE IMMEDIATE ReI'AIR OF LacEKATIONS I\ THE 

Cemtal Tkact Oocukrixc; in Lahou 

Apfolsteclt : Berliner kliii. ^^'ocllens., No. 48, 1906. 

Assareto: La Ginecologia, vol. 4, p. 423, 1907. 

Coles: Surgery, Gynecolog}', and Obstetrics, Xoveniber, 1906. 

Davis: Progressive Medicine, p. 239, 1908. 

Faivre: Zentralblatt f. Gynakologie, p. 198, 1907. 

Gaillard: L'Obstetriqiie, No. 7, 1909. 

Giierdjikoff: Ann. di Ginecologia, April, 1907. 

Kiister: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 65, 1909. 

Kiistner: Monatsschrift f. Geburtshiilfe und Gynakologie, Bands 29 and 

30, 1909. 
Mayer: Zentralblatt f. Gynakologie, No. 5, 1909. 
Meyer: Inaug.-Diss., Giessen, 1907. 
Ohn: American Journal of Obstetrics, p. 78, 1907. 
Rudaux: Journ. d'Obst. et Gyn., September 20, 1907. 
Sellheim: Miinchener m. ^Yocllenschrift, No. 37, 1909. 
Sigwart: Zentralblatt f. Gynakologie, No. 10, 1909. 
Ulrich: Journal of Obstetrics and Gynecology of the British Empire, 

No. 4, 1907. 
rtendorffer: Inaug.-Diss., Breslau, 1907. 

THE INTERMEDIATE REPAIR OF LACERATIONS OF THE GENITAL 
TRACT OCCURRING IN LABOR 

Hirst has drawn attention to the possibility of repairing lacera- 
tions occurring during labor in from five to seven days after the injury, 
and claims considerable advantage for this method. When the 
swelling and bruised condition so constantly seen immediately after 
labor has subsided and the patient has recovered from the fatigue and 
exhaustion of childbirth, the operator can secure the conditions essen- 
tial for a successful operation, and the patient is in good condition 
for complete anesthesia. In carrying out this method no attempt 
is made to close lacerations immediately after labor unless hemorrhage 
is evidently coming from a torn vessel. Should this be the case, the 
vessel must be caught and tied or deep stitches passed to control it. 
The parts are kept aseptically clean and the general condition of the 
patient receives attention. A^'hen the tissues are in good condition 
the operator selects a favorable time and, under aseptic technic, 



414 OPERATIVE OBSTETRICS 

repairs the lacerations with complete anesthesia. If the torn surfaces 
have completely glazed over, they may be gently scraped with the 
blade of a pair of scissors or with a sharp curet, until they ooze 
slightly. The torn cervix is then first repaired, and afterward the 
segments of the pelvic floor and perineum. 

It is claimed by those who advocate this method that the patient's 
puerperal period is shortened, that involution i)roceeds rapidly, that 
the operator is enabled to accurately close the wounds, and that 
wounds heal completely and without loss of substance. 

The writer has not tried this method because closure within twenty- 
four hours after the occurrence of lacerations has given him good 
results, and he has hesitated to disturb the patient's puerperal period 
as late as the fifth or seventh day. 

Bibliography of Intermediate Repair of Injuries to the 
Genital Tract 

Hirst: Text-Book on Obstetrics. 

Ischernoff : Inaug.-Diss., St. Petersburg, 1907. 

THE LATE REPAIR OF LACERATIONS OF THE GENERATIVE TRACT 

After a patient has recovered from childbirth with permanent 
lacerations of the generative tract, the question arises as to whether 
operation should be undertaken for the repair of such lacerations, 
when this had best be done, and to what extent should such lacera- 
tions be closed. 

The necessity for the repair of lacerations will depend somewhat 
upon the fact as to whether the patient is or is not nursing her child. 
Complete anesthesia disturbs lactation for a short time, and the claim 
has been made that lacerations do not heal as promptly and soundly 
when lactation is in progress as when the operation is done in the 
absence of nursing. Unquestionably it is desirable, if possible, to 
operate upon a patient who is not nursing a child. 

The time to be chosen for the repair of lacerations will depend 
considerably upon the condition of the patient's tissues. In cases 
with relaxed fiber with subinvolution the effort to perform secondary 



LATE KErAlK OF LACKHATIONS OF THE GENERATIVE TRACT 415 

repair by dissecting scar tissue, and possibly by making flaps, will 
be accompanied by free hemorrhage which may jeopardize the success 
of the operation. In the i)resence of subinvolution cureting the 
uterus is a dangerous i)rocedure, as the curct is easily ohrust through 
the softened uterine muscle. If the womb is in fair position and the 
patient's general condition is good, the operator should certainl}^ 
delay until the tissues are sufficiently contracted to avoid severe 
hemorrhage. 

The presence of infection contraindicates operation. If the pa- 
tient recovers from childbirth with endometritis, this should receive 
proper treatment before the cervix is closed or incisions are made in 
the pelvic floor or perineum. A severe pelvic or general infection 
will be lighted up if this caution be disregarded. In patients recover- 
ing from septic infection the general condition is not good, and sound 
and prompt union cannot be expected after operation. In general, 
it may be said that the patient must have regained a fair degree of 
health, the tissues must not be hyperemic, and infection must be 
absent for secondary repair to be successful. 

In choosing the method of operation the entire generative tract 
should receive attention. As subinvolution is often present, the uterus 
should be dilated, gently cureted, and packed with antiseptic gauze 
to stimulate its contraction. If the patient be a multipara, with an 
enlarged and badly torn cervix, amputation of the cervix is indicated. 

If the cervix be in good condition the lacerated scar tissue 
should be removed and the torn edges brought in apposition and closed 
by chromicized catgut sutures. In women who have not passed the 
child-bearing stage the mistake must not be made of attempting 
the complete closure of the cervix. In our experience a patient had 
been operated upon for repair of the cervix, and the dissection and 
suture had been carried so far in the cervix as to encroach upon the 
site of the lower uterine segment. In a subsequent pregnancy 
placenta prsevia was present, and dilation of the cervix to perform 
version or deliver the child was very difficult by reason of the pre- 
vious closure, and severe laceration into the lower uterine segment was 



416 OPERATIVE OBSTETRICS 

prevented with great difficulty. We have repeatedly seen the cervix 
tear extensively after its complete repair. In women who haA'e not 
passed the child-bearing period the cervix should be repaired suffi- 
ciently to prevent its chronic congestion and degeneration, but not so 
completely as to make a subsequent dilation difficult. 

The Late Repair of the Pelvic Floor. — It is interesting to observe 
that the only practically successful and satisfactory operation for the 
secondary repair of the lacerated pelvic floor is based upon the correct 
closure of recent lacerations. The value of the Emmet denudation 
lies in the fact that it reproduces the original lacerations in the vagina, 
sulci, and levator ani muscle. Keeping this fact in mind, the obstet- 
rician can plan the extent of the denudation after Emmett's method 
in accordance with the conditions present in each case. Remember- 
ing that the original tear occurs most frequently upon the left side, 
it is usually necessary to carry the denudation higher upon the left 
than upon the right side. The apex of each denudation should extend 
to the highest point in the vaginal sulcus where prolapse of the tissues 
and rectocele are present. It is sometimes difficult to reach this point 
successfully, and in extensive injuries the denudation should be 
deep enough to take in the fascia forming the ureterosacral liga- 
ments. The insertion of sutures of silkworm gat should begin at the 
apex of each denudation, and the operator can judge of the effect in 
his operation by observing the degree to which the pelvic floor is 
I'aised and the posterior vaginal wall brought upward toward the 
anterior vaginal wall as the sutures are tied. 

In denuding for the repair of the perineum the operator should 
fo'st examine carefully the sphincter muscle of the bowel. If this be 
sound, less extensive denudation is required than where the muscle 
or its fascia has been torn and is permanently relaxed. If the sphincter 
requires attention, sufficient dissection should be done to expose its 
fascia and, if possible, its severed muscular fiber. These ends 
should be denuded and the sphincter and its fascia closed separately 
with buried stitches of medium-sized catgut. In cases of extensive 
denudation the perineal body must be built up by buried catgut 



LATE REPAIR OF LACERATION'S OF THK HEXERATIVK TRA( T 417 

stitches as the operator proceeils. The placing of 1 jiinut's crown 
stitch clepemb u|X)n the degree of laceration present, and should be 
left until the last, as in the repair for recent laceration the oixrator 
waits until the end of the operation before bringing the sutures in 
the pelvic floor to meet the line of suture in the perineum. 

It is imix>ssible to describe muiutely the technic rec^uisite in each 
case, but the obstetrician who is skilled in closing recent lacera- 
tions will have little difficulty in adjusting the same principles to the 
secondary- and late repair. 

In patients in fair general condition it should be possible to dilate 
and curet the uterus, amputate or close the cenix. and repaii* incom- 
plete lacerations of the pehic floor and perineum at one sitting. 
Should there be an extensive complete laceration, with extensive tear 
of the cervix as well, with laceration of the anterior segment of the 
pehic floor, in a patient who is in bad condition, it may be necessar\^ 
to divide the operation, closing the cenix and anteri(3r segment at 
one sitting, and reserxTng the posterior segment of the pehic flexor 
for a second operation. 

The Secondary Repair of Complete Lacerations of the Pelvic Floor 
and Perineum. — In these cases^ as in the incomplete, the operator 
must first reproduce essentially the anatomic conditions present after 
the recent laceration. As the mucous membrane of the rectum has 
atrophied and retracted, it would be necessary to replace it by flaps 
formed by dissection. As in the recent complete laceration the opera- 
tor first closes the torn rectal wall, so in the secondaiy operation the 
operator first forms a new rectal wall by flap dissection, and then 
proceeds to close it essentially m the same manner as in the recent 
case. It is especially important in these cases that the renmants 
of the sphincter muscle be identified and freely loosenal from their 
retracted condition by dissection. WTien this has iDeen done the 
sphincter may be re-formed with buried sutures of catgut. .Although 
it may be difficult to identify muscular fiber in its atrophied condition, 
experience shows that if even a portion of the muscular fiber can be 
secured, and the fascia be properly closed, a seniceable sphincter may 



418 OPERATIVE OBSTETRICS 

be formed. After the rectal wall and sphincter muscle have been 
restored, the vaginal sulci and pelvic floor may be repaired in accord- 
ance with the anatomic condition present. The extent to which 
the perineal body can be restored will depend upon the degree of 
atrophy present. The operator must remember the comparative 
unimportance of the perineal body in maintaining the integrity of 
the genital tract. It is a mistake to attempt to re-form the peri- 
neum where the tissue has been greatly atrophied, and the effort to 
do so will cause tension upon the stitches which may jeopardize the 
success of the operation. 

The Secondary Repair of Lacerations of the Anterior Segment of 
the Pelvic Floor. — Prolapse of the anterior vaginal wall with cysto- 
cele may be satisfactorily corrected by the denudation of an oval 
surface whose size depends upon the degree of laceration and prolapse 
which is present. If the tissues about the urethra have been torn 
and the urethra has sagged downward and forward, this condition will 
not be entirely corrected by operation upon the anterior vaginal 
wall only. Should the latter be too extensively carried out, it w^ould 
draw^ the urethra upward and backward and might cause the patient 
considerable discomfort. 

To correct prolapse of the urethra the anterior vaginal wall may 
be repaired, and this should be accompanied by bilateral denudation 
at the sides of the urethra, and the closure of these surfaces by sutures 
inserted almost at right angles to those which close the denuded sur- 
face in the anterior vaginal wall. 

Bibliography of the Late Repair of Lacerations of the 
Genital Tract 
Ahlfeld: Deutsche med. Wochens., No. 51, 1907. 
Anspach: American Journal of Obstetrics, December, 1906. 
Barry: The Lancet, November, 1906. 
Baum: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 22, Heft 

4, 1905. 
Brickner: American Journal of the Medical Sciences, No. 425, 1907. 
Child: Journal of Obstetrics and Gynecology of the British Empire, 

November, 1905; American Journal of Obstetrics, October, 1906.. 



CORRECTION OF UTERINE DISPLACEMENTS FOLLOWING LABOR 419 

Diihrssen: CJyn. Rundschau, Heft 2 and 8, 1907. 

Goffe: American Journal of Obstetrics, October, 1906. 

Hall: Surgery, Gynecology, and Obstetrics, February, 1909. 

Holden: American Journal of Obstetrics, October, 1905. 

Jacobs: Zentralblatt f. Gynakologie, No. 9, 190S. 

Kiistner: Monatsschrift f. Geburtshiilfe und Gynakologie, Heft 2, 1908. 

Meyer: Dissertation, Giessen, May, 1907. 

Nagel: Arcliiv f. Gynakologie, Band 75, Heft 2, 1905. 

Paramore: British Medical Journal, February 6, 1909. 

Watkins: Surger}^, Gynecology, and Obstetrics, February, 1909. 

THE CORRECTION OF UTERINE DISPLACEMENTS FOLLOWING 
LABOR, WITH OR WITHOUT LACERATIONS 

In many cases retroversion or exaggerated anteversion with pro- 
lapse are distinctly caused by lacerations. Under these circumstances 
the repair of lacerations will be followed by the correction of the 
uterine displacement. 

To further this, after the patient has recovered from operation, 
the uterus should be raised in the pelvis, and, if necessary, anteverted 
by the knee-chest posture, accompanied, if necessar}^, by the tempo- 
rary use of the antiseptic wool tampon or a carefully fitted soft-rubber 
pessary. If, however, the correction of subinvolution and the 
repair of lacerations does not improve the position of the uterus, 
abdominal section may be performed and the malposition corrected 
by operation upon the round ligaments or upon the round ligaments 
and broad ligaments. Theoretically the ureterosacral ligaments 
should also receive attention in such sections. 

Practically, the writer has not found it satisfactory to attempt 
such intra-abdominal repair. The intraperitoneal shortening of the 
round ligaments by Gilliam's, Baldy's, or other methods should 
be selected, the operator choosing that form of operation which is 
best adapted to the anatomic condition present. The writer has 
had good results by shortening the round ligaments by the method 
described and practised by Dudley. If the operator is satisfied that 
this operation is necessary, it may be advantageoush^ performed 
following cureting of the uterus and repair of the cervix. The repair 



420 OPERATIVE OBSTETRICS 

of the pelvic floor and perineum may be included at the same sitting 
or may be deferred to a subsequent operation. Intra-abdominal cor- 
rection of uterine displacements may be practised after labor as soon 
as involution is fairly well advanced and the patient has recovered 
from the exhaustion of labor. It should be included among obstetric 
operations, and is as appropriate a part of obstetric surgery as the 
repair of lacerations. 

The Correction of Prolapse of the Pelvic Viscera Following Labor. 
— Where extensive lacerations of the generative tract are present, 
with subinvolution, the correction of these conditions must precede 
operation for prolapse. In severe cases the operator must decide 
whether the patient's interests will not best be served by sacrificing 
the uterus rather than by attempting to retain it in position. If the 
patient is approaching the menopause it may be best to remove the 
body of the uterus with the tubes and ovaries, bringing together the 
peritoneal surfaces of the broad ligaments in such a manner as to sus- 
tain the stump of the uterus at the summit of the vagina and pre- 
vent prolapse of the vaginal walls. If the patient decHnes to sacrifice 
the uterus, and further conception is unlikely, ventrofixation may be 
performed following the closure of lacerations. 

Polk^ describes and illustrates a suprapubic operation on the 
pelvic floor for prolapse of the uterus. The operation consists essen- 
tially in opening the ureterovesical space, separating the bladder 
from the vagina, pushing aside the ureters, and exposing the anterior 
w^all of the vagina beneath the bladder. The anterolateral lines of 
the vagina are then united with continuous kangaroo tendon sutures 
on each side from below upward, beginning as far down as possible, 
and uniting below the upper end of the original incision. The bladder 
is held forward with a retractor. The fascia of the peritoneum cover- 
ing the sides of the bladder, the vagina, and uterus is now united in 
the median line, the ureters and uterine arteries being left outside the 
sutures. The ureterosacral ligaments are then shortened at the junc- 
tion of the inner and middle thirds. If the uterus be retained, the 
1 American Journal of Obstetrics, vol. 60, No. 3, 1909. 



CORRECTION' OF ITERIXK DISPLACEMEXTS FOLLOWING LABOR 421 

round ligaments may be shoiteneil in addition. If tlie uterus be senile, 
it may be tlu-own forwaixl and the fundus held in the sulcus behind the 
bladder by passing the sutures through the round ligament at each 
cornu. If the uterus is removetl, the cut surfaces of the stump are 
stitched together in the line of the original incision. After closing 
the abdominal wound, if necessary, the perineum may be repaired in 
the lower portion of the posterior vaginal wall. 

In a patient presentei:! for examination upon whom this operation 
had been performed, the vagina had a normal depth and the neck of 
the uterus was encircled by a plastic infiltration wliich was not painful 
upon pressure. The patient's prolapse had been cured. 

In some cases of prolapse the operator's ingenuity may be taxed 
to the utmost to secure a favorable result. In women who liave 
long-continued nen'oiis strain and are badly nourished the entire 
nmscular and elastic tissues of the body are so wasted and relaxed that 
there seems to be no point from which to form supporting tissue. 
The broad ligaments share in the general relaxation and atrophy, and 
it may be practically impossible to prevent prolapse. 

Bibliography of Operation's for Displacemext axd Prolapse 

Barrett: American Journal of Obstetrics. Jime. 1907; Surgeiy, Gyne- 
cology' and Obstetrics, April, 190S. 

Besserer: Zentralblatt f. Gynakologie, Xo. 19. 1907. 

Bourcart: Ann. de G^'n. et d'Obst., December. 1907. 

Coffey: Sm-geiy. Gynecology', and Obstetrics. October. 1908. 

Diihi-ssen: G}"n. Rimdschau. Heft 2. 1907. 

Discussion, British Medical Association: British Medical Journal. 
October 1. p. 2S:3, 190S. 

Haupt: Monatsschrift f. Gebuitshiilfe und G>iiakologie. Band 25. 1907. 

HUl: American Journal of Obstetrics. May. 1907. 

Kiistner: Monatsschrift f. Gebuitshiilfe und G^iaakologie, Band 26. 1907. 

Macray: Arcliiv f. G\'nakologie. Band SS, Heft 3. 1909. 

Martin: Surgeiy. G^-necolog}'. and Obstetrics, Febiaiaiy. 1907. 

Sippel: Monatsschrift f. Gebuitshiilfe und G>Tiakologie. Band 26. 1907. 

Strassmann: BerHner klin. Wochens., Xo. 33, 1907. 

Taylor: Joirmal of Obstetrics and G>Tiecolog>- of the British Empire. 
December. 1907. 

TiUmann: Beitrage zur klin. Chir.. Band 55. 1907. 



422 OPERATIVE OBSTETRICS 

DIASTASIS OF THE RECTI MUSCLES AND RELAXATION OF THE 
ABDOMINAL WALL FOLLOWING LABOR 

These conditions are most commonly seen in anemic multiparse 
who have born children rapidly with insufficient recovery after 
labor. If the condition be extreme, every effort must be made to 
build up the patient's general health and, if possible, to bring about 
an improved condition in the muscles of the abdominal wall by 
gentle massage. At operation the redundant skin and fascia may 
be excised, the upper and lower fascia of the recti muscles identi- 
fied and isolated, and separately closed with buried catgut stitches. 
If hernia has developed, the contents of the hernia must be replaced, 
the sac excised, and its edges accurately approximated. 

THE TECHNIC OF OPERATIONS FOR THE REPAIR OF LACERA- 
TIONS AND THE CORRECTION OF DISPLACEMENTS 

The tissues of the cervix, pelvic floor, and vagina may be rendered 
in better condition for operation by douches, twice daily for several 
days, with 1 per cent, lysol. If catarrh of the bladder be present the 
bladder may be irrigated once daih' with dilute argyrol or salt solu- 
tion. Where complete laceration of the perineum must be corrected, 
the bowel should be thoroughly emptied several times before opera- 
tion and the rectum irrigated daily with salt solution. 

Operators generally agree in closing the surfaces covered with 
mucous membrane b}' a catgut or kangaroo tendon suture. Chi'omi- 
cized catgTit lasts sufficiently long to permit the heaUng of the 
torn cervix and has largely replaced silver wire. Some operators 
prefer to use tliis also in repairing the cutaneous surfaces of the 
perineum. In the Emmet operation many operators prefer silkworm 
gilt because the sutures are difficult to cleanse perfectly after opera- 
tion and silkworm gut does not become infected. The kangaroo 
tendon is especially appropriate for continuous suture in peritoneal 
surfaces where the suture is to remain for some time, acting as a splint 
for the tissues. Silk is rarely used except in some cases of ventro- 
suspension where the operator prefers to unite the uterine and abdom- 
inal peritoneum with buried stitches of fine silk. 



TECHNIC OF OPER.\TIONS F )R THE REPAIR OF LACERATIONS 423 

Improvements in obstetric surgery have greatly simplified the 
technic of these operations. Dissection with blunt-ix)intecl scissors 
can be rapidly efifected with comparatively- little hemorrlmge, im- 
proved appliances for lighting the field of operation, and better 
facilities for placing the patient in a favorable position, have rendered 
the performance of these operations muck more simple and satis- 
factory-. The univei-sal adoption of antiseptic precautions with 
aseptic care of the patient has rendered the occurrence of infection 
rare, while hemorrhage of gravity dining or after these operations 
ver}' seldom occurs. The after-care of patients operated uix)n for 
laceration of the pehic floor and perineum requires skilful nm^ing 
and especial precautions to avoid the infliction of injurj^ upon the 
patient. Stitches in the pehic floor should be cleansed by ix)uring 
sterile or antiseptic solutions upon them. The insertion of the 
finger, gauze, or cotton within the vagina should not l^e i>ermitte<:l. 
Some operators prefer in addition the use of a dusting-powder of 
iodoform and boric acid after irrigations of antiseptic solutions. 

The After-treatment of Complete Lacerations of the Pelvic Floor. 
— After repair of the ccrii^: ■rte laceration of the peiAic z: : ■:■:.'. 
perineum especial attention must l:>e giAen to the condition ^-i iric 
bowels. On waking from ether such patients sometimes complain 
bitterly of pain in the rectum and about the anus. If this sufifer- 
ing be not promptly controlled, the patient may strain severely and 
tear asimder the sutured surfaces. Such pain must be promptly held 
in check by opium, given as morjDhin h\-podermically or in sui>- 
positories inserted into the bowel. If the patient has considerable 
pain after operation she should have sufficient opiimi to keep her 
comfortable. If she has been thoroughly prepared the bowels need 
not move for two or three days after operation for the complete tear. 
The patient should take some laxative which wiU soften the fecal 
matter, such as castor oil or compound Ucorice powder, and should 
be instnictetl to warn the niu-se when she feels a desire to empty the 
bowels. From 8 oimces to a pint of warm sterile oUve oil should be 
carefully injected by a large soft-rublDer catheter as high in the bowels 



424 OPERATIVE OBSTETRICS 

as possible. After the fecal matter has been passed the bowels should 
be gently irrigated with warm sterile salt solution. After the initial 
movement the bowels should move daily or every two days. 

Bleeding and Infection After the Repair of Lacerations. — Should 
hemorrhage occur after secondary operations for repair, the operator 
must locate, as far as possible, the site of the hemorrhage. This 
may not be easy to accomphsh. for blood may ooze from a point high 
up in the tissues and form a considerable accumulation in the surround- 
ing cellular tissue. If the bleeding is not extensive, an effort may 
be made to check it by tamponing the area of operation with 10 per 
cent, iodoform gauze with the application of a large pad of gauze over 
the Aiilva. By this means the operator may try to avoid remo^-ing 
the stitches, hoping that the extravasated blood will gradually clot 
and subsecjuently be absorl^ed. If the hemorrhage is considerable 
and can be traced to its source, it may be necessary to remove one 
or more stitches to secure a blt^eding vessel, and again close the 
incision. 

In the rare event of infection following these operations the 
stitches shouLI be freely remoA'e'I an^l the parts copiously douched 
with (lilute antiseptic solutions anil powdered with iodoform and 
boric acid. 

The Patient's Convalescence After the Repair of Lacerations. 
— An opportunity should be taken after these operations to correct 
the patient's anemia by iron, arsenic, a suitable diet, and by general 
massage. AAliere excreiion is habitually deficient this should receiA'e 
proper stimulation. The patient's recovery will be but partial if 
the general health does not receive adecpiate attention. 

THE SURGERY OF PUERPERAL SEPTIC INFECTION 

AATiile antiseptic precautions have greatly lessened puerperal 
septic infection in hospital practice, the fact that many general prac- 
titioners do not efficiently employ antiseptic precautions in obstetric 
practice gives rise to a consideral")le number of such cases. The 
performance of criminal abortion, the care of obstetric patients by 



THE SURGERY OF Pl-ERPERAL SEPTIC IXFECTIOX 425 

incompetent mi I wives, antl the preWous existence of gonorrheal and 
syphilitic infection contribute to the number of these cases. 

Emptying the Septic Uterus. — In the presence of puerperal septic 
infection the interior of the uterus has been at some time involved. 
The decision to explore the uterine cavity with the hope of remov- 
ing retained tissue must be made in accordance with the conditions 
j»esent. The operator is called to a patient recently delivered 
with offensive lochial discharge, mi enlarged, sli^btly softened and 
sh^tly teader uterus, ami it is quite probable that retained portions 
of placenta, membranes, or blood-clot are still present. If^ however, 
he sees his patient a week or ten days after labor, finding no exces- 
ave discharge from the uterus, but a colorle^ dark prune-juice 
fluid, with symptoms of streptococcus infection of the Hood^ the 
uterus fairly well involuted and the cervix almost closed, it is doubt- 
ful whether the interior of the uterus requires exploration. It is 
probably safer to explore all septic uteri once as soon as possible 
after the case is seen, unless the conditions are such that thi- ex- 
ploration will add to the patient's shock and may increase the absorp- 
tion of streptococci into the blood-current. 

The exploration and emptying of the septic uterus fe an opera- 
tion requiriug judgment, patience, and oftentimes coi^deraHe 
skilL The operator must remember that the conditions are pecu- 
liarly favorable for puncture of the uterine wall. The uterine muscle 
is softened, esjjeciaUy at the area where the placenta was attached, 
which is frequently the site of infection, and may be in a partially 
necrotic condition. Hence all sharp-poiated instruments should 
not be introduced within the uterine cavity. For exploratory pur- 
poses the fingers of the ^oved hand are safest. A large blunt-edged 
spoon curet with a hollow handle serves the douWe purpose of ex- 
ploring the uterine cavity and of introducing a gentle current of 
antiseptic Quid. Swabbing out the interior of the septic womb 
with sterile gauze in the grasp of uterine dressing forceps Ls preferred 
by some. This is essentially the method of the French, who cleanse 
the puerperal womb with an aseptic brush rotated within its cavity. 



426 OPERATIVE OBSTETRICS 

To explore and empty the puerperal septic uterus, anesthesia is 
required if the uterus is very sensitive to pressure and the patient 
excitable and suffering pain. Some septic patients are so apathetic 
that the operation may be done without anesthesia. As the cervix 
is sometimes partially closed in these cases, the operator must be 
prepared to dilate it with the fingers or with solid dilators. After 
suitable preparation the cervix is dilated sufficiently to admit one or 
two fingers, the uterus pressed gently downward, and the uterine 
wall explored by touch as completely as possible. If a piece of 
retained placenta be found it should be brought away. If there 
be no retained placenta, but an abundance of affected decidua, and 
the operator can find no point of rupture in the uterus, the uterine 
wall should be gently scraped with a blunt curet. When the operator 
is satisfied that the uterus has not been punctured, its cavity should 
be gently irrigated with hot salt solution or 1 per cent, lysol. The 
cavity may then be packed to advantage with 10 per cent, iodoform 
gauze, serving the double purpose of exciting uterine contraction, 
promoting drainage, and exercising an antiseptic influence upon 
the bacteria within the uterus. In cases of severe streptococcus 
infection this manipulation may be accompanied or followed by severe 
uterine hemorrhage. This requires the firm use of the gauze tampon 
and the administration of strychnin, ergot, and adrenalin. The 
gauze tampon has the added advantage that its pressure promotes 
the loosening and subsequent discharge of pieces of retained placenta 
or membrane. The gauze is removed from forty-eight to seventy-two 
hours after its insertion. Should the operator find that he has punc- 
tured the uterus during this manipulation, he must decide whether 
to open the abdomen or whether he can deal safely with the condi- 
tion without such procedure. If no fluid has been employed within 
the uterus, and the finger or curet has been thrust through the uterine 
wall at one point only, the operator must introduce a strand of iodo- 
form gauze through this aperture, draining the uterus with iodoform 
gauze, and hoping to avoid the necessity for section. If, however, 
fluid has escaped through the puncture in the wall of the uterus, 



THE SURGERY OF PUERPERAL SEPTIC INFECTION 427 

abdominal section is safer, followed b}^ drainage through the vagina 
or through the lower portion of the abdominal incision. Extensive 
rupture of the uterus with bleeding may render hysterectomy neces- 
sary. When the gauze packing has been removed from the septic 
uterus, it should be gently irrigated with salt solution or dilute lysol, 
and after this the uterine cavity should not be disturbed. 

No more serious mistake can be made in dealing with septic cases 
than the repeated use of intra- uterine or vaginal injections. Once 
is quite sufficient to interfere with the uterine cavity. 

Hysterectomy for Puerperal Septic Infection. — Septic metritis 
following labor suggests hysterectomy followed by free drainage of 
the pelvic cavity. This procedure received a thorough trial, when 
abdominal surgery was first extensively practised. The majority 
of obstetricians came to the conclusion that to be successful this 
operation must be performed so early that the operator could not be 
sure of its absolute necessity. If delay was practised until othfer 
methods had failed, the operation was done too late and hastened the 
patient's death. Recently hysterectomy for puerperal septic infec- 
tion has been revived, but has not been widely accepted. 

In performing the operation one of two methods may be chosen. 
If the infection be recent, the general peritoneum not involved, and 
no focus of infection be detected in the pelvis or broad ligaments, 
the operator may remove the body of the womb with the Fallopian 
tubes and one ovary, leaving the remaining ovary to prevent a prema- 
ture menopause. The pelvic cavity should be drained after this 
operation by a strand of gauze passed behind the stump of cervix 
through the vagina or through the lower end of the abdominal incision. 

If the condition of the patient does not justify an operation re- 
quiring as much time as hysterectomy with intraperitoneal treatment 
of the stump, the Porro operation may be selected, leaving the uter- 
ine stump at the lower end of the abdominal incision and closing the 
peritoneum accurately around the stump. 

The Complete Extirpation of the Septic Uterus. — Some operators 
prefer the complete extirpation of the septic uterus to hysterectomy. 



428 OPERATIVE OBSTETRICS 

This may be done through the vagina in multiparous women in whom 
the vagina has been repeatedly distended. In primiparous women 
the complete extirpation of the uterus may best be accomplished by 
abdominal section, followed by drainage of the pelvic cavity with 
iodoform gauze inserted from above downward. The retention of- 
one or both ovaries will depend upon the age of the patient, and 
must be decided in accordance with the circumstances of each indi- 
vidual case. 

Some aid may be obtained in making a decision to select or reject 
hysterectomy by the bacteriologic examination of the uterine lochia, 
and the bacteriologic examination of the patient's blood. If strep- 
tococci be present in the blood it is too late to perform hysterectomy, 
and the patient's chance for recovery will be lessened by the opera- 
tion. If the blood is sterile, and the uterine lochia shows the abun- 
dant presence of several varieties of pathogenic bacteria, a mixed 
uterine infection may be diagnosticated and hysterectomy may im- 
prove the patient's condition. The presence of fibroid tumors in 
the wall of the septic uterus requires hysterectomy, as infection in 
these cases is especially dangerous. 

The Surgical Treatment of Pelvic Thrombophlebitis. — The excision 
or ligation of thrombosed and infected veins of the broad ligament 
proposed by Trendelenburg is now recognized as a justifiable pro- 
cedure in the early stages of puerperal pyemia. The theory of this 
operation is the prevention of the absorption of bacteria and toxins 
from the infected thrombi by hgating the continuity of the vein, thus 
checking the blood-stream at this point. The excision of infected 
veins after Hgation removes foci of infection. 

The symptoms indicating this procedure are chills, followed by 
high fever, rapid pulse, and general symptoms of puerperal infec- 
tion. On vaginal examination the large veins can be made out Hke 
cords beneath the mucous membrane. Peritonitis may be present, 
making the examination difficult and painful. 

The operation is performed by opening the abdomen, exposing the 
infected veins, and passing chromicized catgut ligatures beneath them 



THE SUKCERY OF PUERPERAL SEPTIC INFECTION 429 

as high in the broad Hgaiiients as possible. If th(» conditions are 
favorable the thrombosed portions of the veins may be removed. 
Unless pyosalpinx has definitely developed, it is well to hmit the 
operation to the ligation of the veins only. 

If the operation has done good, the patient's chills grow less and 
finally cease, the temperature and pulse sink, and the patient's gen- 
eral strength increases. There will remain, however, considerable 
thickening in the tissues of the broad Hgament at the site of ligation. 

The Surgical Treatment of Thrombophlebitis of the Lower Extrem- 
ity (Milk Leg). — This most common form of phlebitis following 
labor may be divided into two classes: In the first are those cases 
in which the source of infection cannot be traced, in w^hich little, if 
any, rise of temperature occurs, and in which surgical interference 
is not necessary. In these patients there is moderate tenderness only 
over the vein or veins involved, the lower extremity is but moderately 
swollen, and the tension on the skin and fascia is not excessive. In 
some cases fever is absent and the constitutional disturbance is very 
slight. 

With these patients elevation of the lower extremity, the appli- 
cation of lead-water and laudanum over painful areas, and bandaging 
the lower extremity from the toes to the groin are sufficient. Con- 
valescence proceeds steadily, and recovery follows in from two to 
three wrecks. 

In severe cases tenderness and pain at the site of the thrombosis 
are pronounced, the patient has considerable fever, swelling of the 
lower extremity is well marked and accompanied by considerable 
pain, the subcutaneous tissue may become infected, and phlegmon 
may develop. Multiple incisions in the lower extremity may be 
indicated for the purpose of draining the infected serum and pus. 
In extreme cases sloughing to a greater or less extent takes place. It 
may be necessary to insert drainage-tubes through various portions 
of the thigh, and the patient's recovery is prolonged and tedious. 

The site of infection in these cases, whether they be slight or 
severe, is undoubtedly the uterine wall where the placenta has been 



430 OPERATIVE OBSTETRICS 

attached. The blood-stream has become infected and the thrombosis 
is determined by the anatomic conditions present. 

Pelvic Abscess. — In cases of mixed infection which spread from 
the vagina and cervix into the pelvic tissues, pelvic abscess may 
develop. If left without interference and the patient's resisting 
power proves sufficient to encapsulate the abscess, it may finally 
burst into the rectum, the bladder, or into the vagina. Such a result 
should not be awaited, but as soon as bogginess and obscure fluctuation 
develop in the posterior vaginal fornix a free incision should be 
made and the pus allowed to escape freely. The abscess cavity 
should not be irrigated to avoid the danger of spreading infectious 
material into the peritoneal cavity. The fingers of the gloved hand 
may cautiously explore the abscess and, if it be thoroughly walled off 
and pyosalpinx be present in the abscess wall, the pyosalpinx ma^ 
also be incised and allowed to drain through the vagina. A drainage- 
tube may be inserted, and later a gauze drain, until the abscess. 
has completely emptied itself and the cavity is well-nigh closed 
by granulation. If the patient's infection be severe she should be 
placed in Fowler's position and saline fluid introduced freely into the 
circulation by the Murphy method or by intravenous saline trans- 
fusion. In draining such an abscess every precaution must be taken 
not to open its wall upon the abdominal aspect, to avoid infecting the 
peritoneum. No attempt should be made in these cases to perform 
a complete operation upon the uterus, tubes, or ovaries until the 
local infection has entirely subsided. When this result has been 
secured and the general condition of the patient is good, the abdomen 
may be opened, adhesions loosened, diseased tubes or ovaries removed, 
or the pelvis cleared by removal of the tubes and ovaries, including 
the body of the uterus. Should this operation be undertaken too early 
the manipulation necessary will cause general peritonitis, which often 
proves rapidly fatal. Should the patient recover from the pelvic ab- 
scess, retaining the tubes, ovaries and uterus, adhesions may form, 
limiting the mobility of the pelvic viscera and interfering with sub- 
sequent pregnancy and labor. 



THE SURGERY OF TUERPERAL SEPTIC INFECTION 431 

In this connoction mention must be made of Pryor's method of 
treatment, which consisted in incising the posterior vaginal fornix 
widely, emptying collections of pus, loosening adhesions, and filling 
as far as possible the pelvic cavity with layer upon layer of iodoform 
gauze. This was allowed to remain for several days, acting as a 
drain and as a local antiseptic as well. Pryor's treatment in appro- 
priate cases was efficient and gave satisfactory results. In his obser- 
vations iodin could be detected in the urine of the patient shortly 
after the insertion of the gauze and undoubtedly acted as the essential 
antiseptic agent. 

Puerperal Peritonitis. — This serious form of puerperal sepsis is 
recognized as among the most dangerous varieties of peritonitis. It 
may follow the gradual development of severe septic infection from 
a focus usually in the cervix, the infection spreading through the 
endometrium to the tubes, to the peritoneum covering the uterus, and 
thence to the general peritoneum. In its severest form the patient's 
power of resistance is often so slight that no reaction is manifest. 
The pulse is w^eak and rapid, the temperature sometimes subnormal, 
the abdomen not greatly distended or flat, and the patient's general 
condition that of profound infection. On opening the abdomen 
of such a patient pus will be found in considerable quantity, and the 
peritoneum and intestines coated with yellowish-gray lymph. The 
infection is usually of a mixed nature, streptococci and staphylococci 
being abundantly present, and often the Bacillus coli communis 
in addition. Such a condition frequently follows the bursting of a 
pyosalpinx filled with virulent pus, and is often one of the compli- 
cations following criminal abortion. In the experience of the writer, 
a young woman who had suffered from criminal abortion had symp- 
toms of pyosalpinx. After slight exertion she was suddenly taken 
with diffuse abdominal pain, shock, subnormal temperature, and 
rapid pulse. On arrival at the hospital her condition was so grave 
that operation could not be undertaken. Autopsy showed a bursted 
pyosalpinx and virulent general peritonitis. 

In patients whose strength suffices to offer resistance to infection, 



432 OPERATIVE OBSTETRICS 

puerperal peritonitis develops gradually, with pain, fever, and altered 
pulse, distention of the abdomen, and gradual interference with intes- 
tinal peristalsis. Although the peritoneum is altered, it retains suffi- 
cient vitality to form adhesions, which often tend to limit the spread 
of infection. If pus forms, it is in those localities where a collection of 
fluid becomes most readily encapsulated. In patients of great physical 
strength such peritonitis may subside before pus forms and the patient 
make a prolonged recovery. Much can be done for these patients by 
the continuous use of dry cold upon the abdomen, moderate purga- 
tion, tonic doses of strychnin and alcohol, with the careful use of 
opium if the pain be severe. Operation is not indicated so long as 
the patient is resisting the infection and the symptoms are not severe. 

The surgical treatment of puerperal peritonitis must be conducted 
with a view to securing drainage with the least possible disturbance 
of the inflamed viscera. Where the infection is profound, operation 
is rarely successful. In the most acute stages of puerperal peri- 
tonitis operation may do harm by spreading infection from a focus 
which is being walled off by adhesions or exudate. When, however, 
sufficient time has elapsed for the patient's resisting powder to have 
done what it could, and the patient is threatened with further in- 
fection, operation should be at once undertaken. 

Although pelvic abscess may not be present in general puerperal 
peritonitis, we believe that drainage through the vagina is indicated. 
In our experience, good results have followed the opening of the ab- 
domen in the median line with a thorough but careful, examination 
of the pelvic viscera. Adhesions should be carefully loosened, col- 
lections of pus opened, and during this procedure the general peri- 
toneal cavity walled off as far as possible with gauze. If the uterus 
is dislocated, it should be brought as nearly as possible into a normal 
position above the pelvic brim. The posterior vaginal fornix being 
freely opened, 10 per cent, iodoform gauze is packed lightly into the 
^Delvic cavity between the inflamed organs in such a manner as to 
d^^ain the broad ligaments and pelvis from the brim downward. 
Thfc gauze should emerge through the vagina. 



THE SIKCEHY OF rL'KHl'KKAL SKITIC IXFKCTION 433 

The ivgioii of the appnitlix t^hould also rcccnvo attention, and if 
abscess in this location be pres(uit, it slioukl be separately drained 
by a tube or wick of gauze emerging through the abdominal wall 
from the right lower segment. If the operator believes that the 
general peritoneal cavity shoukl be drained as far as possible, he 
may also insert wicks of gauze or rubber drainage-tubes through the 
left lower abdominal wall and also through the abdominal wall 
of both sides in its upper portion. It is best to avoid the intro- 
duction of saline fluid directly into the abdominal cavity. Great 
benefit will follow the continuous instillation of saline fluid into 
the rectum b}' Murphy's method, or the regular injection of saline 
fluid in quantities of or 8 ounces carried as far as possible into 
the bowel. The abdominal incision may remain open and drain- 
age at this point be also effected by the use of gauze. The patient's 
shoulders should be elevated and she should receive free stimulation. 

While these are not the most favorable cases for treatment, some 
will recover under good surgical care. If when the abdomen is 
opened many firm adhesions be found, these should be disturbed as 
little as possible. No attempt shoukl be made to perform a given 
operation, and the operator must content himself \\'ith inserting 
drainage in such a manner as to disturb the viscera as little as possible. 
In cases which have continued for some time, adhesions to the intes- 
tine may expose the bowel to laceration if an attempt be made to 
loosen the adhesions. Should this occur, the rent should be imme- 
diately closed with fine catgut, and a Mikulicz drain carried down- 
ward among the intestines at the point of rupture. This should be 
packed with strands of gauze which can be gradually removed. 
Considerable injury to the intestines ma}^ require resection of the 
w^ounded portion. 

The writer's experience has convinced him of the value of abdom- 
inal incision with through-and-through drainage in septic cases. 
Incision of the posterior vaginal fornix is useful only in strictly cir- 
cumscribed abscess. The operator obtains but a partial and inac- 
curate knowledge of the condition of the pelvic and abdominal organs 

28 



434 OPERATIVE OBSTETRICS 

by this method. With abdominal incision an accurate diagnosis can 
be made, foci of infection intelligently dealt with, and free drainage 
secm-ed. Some most unpromising cases will recover with this treat- 
ment. 

Multiple Abscess Complicating the Puerperal State. — In prolonged 
puerperal sepsis the patient may become pyemic and abscesses develop 
in the joints, in the cellular connective tissue, in the pelvis, the 
peritoneal cavity, and in the kidney. In the writer's experience a 
woman in prolonged puerperal sepsis had fifteen joint abscesses com- 
plicating her recovery, which required a period of more than six 
months. In these cases the abscesses nmst be opened and drained as 
soon as their presence can be recognized. It is better to incise the 
infected tissue too early than too late. Drainage may be secured by 
gauze, by strands of gauze covered by rubber, or by the soft-rubber 
drainage-tube. Irrigation of abscess cavities should be employed 
with caution, and should be limited to salt solution. Packing and 
drainage with 10 per cent, iodoform gauze will often cause the abscess 
cavity to granulate rapidly. 

Surgical kidney may require nephrectomy or nephrotomy. Such 
patients will become exhausted by pain and long-continued infection 
unless the general vigor be maintained by stimulation with the 
free use of alcohol. While the patient's recovery may be tedious, 
it is often surprisingly good when the nature of the infection is 
considered. The patient may become apparently as well as ever. 

Bibliography of the Surgical Treatment of Puerperal 
Septic Infection 

Antoine: Diss., Halle, 1909. 

Bardeleben: Archiv f. Gynakologie, Band 83, Heft 1, 1907. 

Bell: Journal of Obstetrics and Gynecology of the British Empire, No. 

6, June, 1909. 
Boissard: L'Obstetrique, October, 1908. 
Bollenhagen: Zentralblatt f. Gynakologie, p. 151, 1907. 
Brenner : Monatsschrift f . Geburtshtilfe und Gynakologie, Band 25, Heft 

1, 1907. 
Brothers: Medical Record, vol. 71, p. 334, 1907. 



THE SUKGEIIY OF PUERPERAL SEPTIC IXFECTION 435 

Bimim: Monatsschrift f. (Jebiirtshiilfe iind (lynakologir, l^and 30, Heft 

4, 1901); Proceedings CJemiiin CJynecological Society, vol. 13, p. 
105, 1909; Proceedings lOtli International Congress, Budapest, 
p. 140, 1909. 

Cannada}': American Journal of Obstetrics, vol. 50, p. 608, 1907. 

Corneloupe: Those de Lyon, 1906. 

Cragin : American Journal of Obstetrics, June, 1906. 

Cuff: British Medical Journal, March 3, 1906. 

Cumston: Transactions of the American Association of Obstetricians 

and Gynecologists, vol. 18, p. 121, 1906. 
Discussion, German Gynecological Association: Zentralblatt f. Gyna- 

kologie, Xo. 28, 1909. 
Flateau: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 22, 

p. 500, 1907. 
Friedemann: Zentralblatt f. Gynakologie, No. 23, 1908. 
Fromme: Verh. d. deutschen Ges. f. Gyn., Band 12, p. 785, 1907; 

Miinchener med. Wochens., pp. 241 and 1059, 1907; Zentralblatt 

f. Gynakologie, Xo. 11, 1909. 
Gardener : Journal of Obstetrics and Gynecology of the British Empire, 

January, 1907. 
Gordon: Journal of Obstetrics and Gynecology of the British Empire, 

vol. 2, pp. 17 and 468, 1907; British Medical Journal, vol. 1, 

p. 1479, June 19, 1909. 
Guiciardi: Annali di Ostetricia, X^o. 1, 1906. 
Hammerschlag : Proceedings German Gynecological Society, Band 13, 

p. 377, 1909. 
Hartzog: Berliner k. Wochenschrift, X^o. 20, 1909. 
Henkel : Monatsschrift f . Geburtshiilfe und Gynakologie, Band 28, Heft 

5, 1908. 

Koblanck: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 64, 
Heft 3, 1909. 

KoT\Tiatzky: Atlas, Wiesbaden, Bergmann, 1907; Zeitschrift f. Geburts- 
hiilfe und Gynakologie, Band 59, p. 374, 1907. 

Kritzler: Zentralblatt f. Gynakologie, Xo. 28, 1909. 

Kromer: Deutsche med. Wochens., p. 365, 1907; Proceedings German 
Gynecological Society, vol. 13, p. 223, 1909. 

Kronig: Proceedings German Gynecological Society, vol. 13, p. 336, 
1909. 

Latzko: Wiener klin. Wochens., X'o. 19, 1907; Wiener m. Wochenschrift, 
Xos. 27, 34, 35, 1909. 

Leopold: Zentralblatt f. Gynakologie, p. 193, 1908; Archiv f. Gyna- 
kologie, Band 89, Heft 1, 1909; Proceedings German Gyne- 
cologicol Society, vol. 13, p. 292, 1909. 



436 OPERATIVE OBSTETRICS 

Macan: Journal of Obstetrics and Gynecology of the British Empire, 

October, 1908. 
MacLaren: Surgery, Gynecology, and Obstetrics, June, 1908. 
Martin: Deutsche m. Wochenschrift, No. 6, 1909. 
McKay: American Journal of Obstetrics, October, 1907. 
Menge: Proceedings German Gynecological Society, vol. 13, p. 332, 

1909. 
Opitz: Proceedings German Gynecological Society, vol. 13, p. 325, 

1909. 
Prochownick: Zentralblatt f. Gynakologie, p. 104, 1908. 
Runge : Monatsschrift f . Geburtshiilfe und Gynakologie, Band 29, Heft 

5, 1909. 
Sachs: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 64, Heft 2, 

1909. 
Schmidlechmer : Zentralblatt f. Gynakologie, No. 40, 1909. 
Seitz : Monatsschrift f . Geburtshiilfe und Gynakologie, Band 26, p. 493, 

1907. 
Sellheim: Berliner Klinik, p. 231, 1907. 

Sinclair: Surgery, Gynecology, and Obstetrics, November, 1907. 
Stuart : American Journal of Obstetrics, August, 1906. 
Vineberg: American Journal of Obstetrics, March, 1909. 
von Rosthorn: Proceedings German Gynecological Society, vol. 13, p. 

384, 1909. 
Watkins: American Journal of Obstetrics, vol. 60, p. 503, September, 

1909. 
Williams: American Journal of Obstetrics, Ma}^, 1909. 
Winter: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 21, Heft 

1, 1905. 
Wormser: Proceedings German Gynecological Society, vol. 13, p. 242, 

1909. 

PUERPERAL MASTITIS 
This infection is recognized as developing from one of two causes. 
It has been shown by several observers, the writer among them, 
that the milk within the breast may contain bacteria before the 
child has attempted to nurse and without a discoverable lesion upon 
the nipple or breast. The mother may be without symptoms in 
these cases, but the effort to nurse often results in sHght abrasions 
or wounds of the nipple, through which bacteria from the milk gain 
access to the subcutaneous and cellular tissues. Localized infec- 
tion, becoming an abscess, may speedily develop. The child also 



rrERPERAL MASTITIS 437 

may suftVr from intc^stinal infection after takiii*;- milk from such a 
mother. Breat^t abscess may result, depeixliiig in its extent and duia- 
tion upon the local conditions in the breast. 

In the more usual varieties of breast abscess the wound or abra- 
sion upon the nipple may be recognized as the point of entry of the 
infection. This will usually trav(d along the milk-ducts until a sinus 
has become infected. As the breast becomes turgid with incr(>as(>(l 
secretion the conditions become more and more favorable for the 
formation of pus. 

Abscess frequently occurs in the subcutaneous and areolar tissues 
around the nipple, the infection spreading thence into the deeper 
portions. In extreme cases the breast may become honey-combed, 
and in neglected cases abscesses may burst near the nipple over va- 
rious portions of the breast or in the axilla. 

In treating puerperal mastitis the effort to prevent the forma- 
tion of pus may further its development. Wliile simple engorge- 
ment of the breast will yield safely to fomentation, massage, and 
pumping, should infection be present, these measures serve efficiently 
to increase its vigor and the extent of its development. It is a safe 
clinical rule to avoid fomentation, massage, and pumping if these 
measures properly applied increase the patient's suffering and cause a 
rise in temperature. 

In the presence of beginning locahzed infection in the areola 
about the nipple an incision should be made as soon as possible. The 
prompt emptying of a small abscess in this location may prevent gen- 
eral infection of the breast and bring the attack of mastitis to a 
speedy termination. Even if pus has not formed, no harm can cbme, 
under antiseptic precautions^ from incising the hardened and in- 
flamed area near the nipple. If no focus of infection can be detected, 
but the milk contains abundant bacteria, and if the whole breast 
be slightly sensitive and enlarged, infection of the milk-ducts is un- 
doubtedly present. If abscess has not developed the milk-ducts may 
be at least partially drained, followed by the patient use of the 
breast-pump. The milk should not be taken by the chikl, but should 



438 OPERATIVE OBSTETRICS 

be immediately destroyed. If the patient has had several rises of 
temperature above 101° F., if the pulse remains persistently al- 
though but moderateh^ elevated, and if there has been for several 
days tenderness over one or more areas of the breast, abscess must 
be suspected. AMiile in pronounced cases fluctuation may be detected, 
in manj^ cases it cannot be recognized. If the operator waits for dis- 
tinct fluctuation he may delay until the breast is the site of several 
abscesses. 

The patient's convalescence will be more rapid and complete if 
incision be practised without waiting for pronounced, widespread 
fluctuation. Under anesthesia incisions should be made parallel 
wdth the course of the milk-ducts, first through the areola surround- 
ing the nipple sufficiently to enable the operator to introduce his 
gloved finger. Pressure should then be made in various directions, 
and if infection be present with abscess the infected tissue will yield 
and the abscess be discovered. Should this not occur, other incisions 
should be made over portions of the breast which have been espe- 
cially sensitive, or where redness has developed, or where increased 
resistance or bogginess can be detected by touch. The finger again 
should explore such areas, when an abscess will usually be discovered. 

In draining an infected breast the writer has found great advan- 
tage in thi'ough-and-through drainage with two tubes passing through 
the breast and crossing near the nipple. Incisions may be made 
near the borders of the breast in the two upper and two lower quad- 
rants. With the fingers an effort should be made to find areas of 
softened and infected tissue, to break down such areas, and to estab- 
lish tracts for drainage extending completely through the breast. 
A long curved forceps ma}^ then be inserted thi'ough the original in- 
cision near the nipple, carried through the tissue of the breast, and 
made to emerge at the upper and then at the lower openings. Me- 
dium-sized perforated rubber drainage-tubes should then be clra\^TL 
completely tlii'ough the breast from above doT^mward. These two 
tubes cross in the central opening near the nipple. They are then 
washed thoroughly by an injection of sahne solution with a piston 



rrEHPEUAL INIASTITIS 439 

syringe, i\\v incision nvav the nii)})le drained with a strand of <>;auze, 
and the breast covered with a copious antiseptic dressing. Oncc^ or 
twice dail}^ the tube should be irrigated or syringed out with salt 
solution, with the gauze packing near the nipple renewed. As the 
infection subsides the tubes should be drawn downward from above 
and gradually cut off until they are completely removed. The lower 
opening should be kej^t i)atent by packing with strands of iodoform 
gauze. As soon as possible after operation the patient shoukl assume 
the recumbent or sitting posture to facilitate drainage. 

During the course of puerperal mastitis, although the initial abscess 
may have been opened and drained, others in various portions of the 
breast may develop. These must be separately incised unless the 
through-and-through drainage described by the writer has been 
employed. In the latter event the small abscesses will usually burrow 
through into the drainage tracts and thus discharge their contents. 

A complete diagnosis of the condition present may be obtained 
by a bacteriologic examination of the pus discharged from the in- 
fected breast. Should tuberculous infection be demonstrated, as 
soon as the patient's condition permits the breast should be com- 
pletely removed. If the infection found be streptococci and staphy- 
lococci, free drainage will suffice. 

Mastitis in the Newborn. — The newborn infant may develop 
mastitis without perceptible symptoms and without a perceptible 
lesion through which infection may have entered. In these cases the 
infection may have come through the blood-stream or through some 
slight lesion in the skin about the nipple which has not been per- 
ceived. Redness, swelling, and hardness of the breasts develop, 
followed by the gradual formation of pus Incision should be prac- 
tised as soon as the presence of pus is suspected, and the abscess- 
cavity irrigated with salt solution and packed with sterile gauze. 
Daily irrigation with salt solution should be used until the cavity 
closes. But very little reaction occurs in these cases, the infants are 
little, if at all, disturbed and usually nurse without interruption. 

In prolonged cases of puerperal mastitis, where suppuration has 



440 OPERATIVE OBSTETKICS 

seriously depleted the patient's general strength, removal of the 
infected breast may be indicated. The operation is performed by 
the ovoidal incision, and the breast and its surrounding fat removed 
down to the subjacent fascia. The wound should be drained for 
several days after the removal of the breast. 

Where supernumerary collections of mammary tissue are present 
wliich do not communicate with the normal glands, infection or 
abscess may be threatened through retention of milk. In a case in 
the experience of the writer the patient, a multipara, was, after each 
confinement, greatly annoyed by the swelhng of supernumerary 
breast tissue situated near the border of the axilla. Fortunately, 
this communicated with the mammar}' gland, and pressure, with the 
apphcation of a bandage, and gentle massage sufficed to empty this 
tissue sufficiently to prevent engorgement and formation of abscess. 

Bibliography of Puerperal Mastitis 

Bauer: Zentralblatt f. Gynakologie. Xo. 23, 1906: Monatsschrift f. 

Geburtshiilfe und Gynakologie,, Band 26. p. 265. 1907. 
Blane: Prov. med., p. 594, 1907. 
Colorni: Annali di Ostetricia, Xo. 7. 1908. 
Dodeiiein: Zentralblatt f. Gynakologie. Xo. 49, 1906. 
Dm-and: Lyon med.. p. 661. 1907. 

Haitmann: Miinchener med. ^Yochens., Xo. 6, p. 261. 1907. 
Heil: Gyn. Rundschau. Band 1. p. 203. 1907. 

Heinsium and Lissauer: Deutsche med. Wochens.. p. 2132, 1907. 
Lizwino^\Tcz : Zentralblatt f. Gynakologie. p. 369, 1907. 
Paul: Zentralblatt f. Gynakologie. Xo. 24. 1907. 
Planchu: Journ. d'Obst. de gyn. et de Ped.. July 20. 1907. 
Rouzaud: Journ. de med. de Paris, p. 391, 1907. 
Sauer: Diss.. Erlangen. 1907. 
Singley: Annals of Surgery, p. 672. 1907. 
Stiassny: Gyn. Rundschau. Band 1. p. 5. 1907. 
Trillat and Latarjet: Lyon med.. p. 605. 1907. 
Zacharias: Miinchener med. Wochens.. p. 716. 1907. 



PART IV 
THE SURGERY OF THE NEWBORN 



ASPHYXIA 

Ix dealing with as})hyxia in the newborn the ordinary methods 
of resuscitation practise<;l by obstetricians are usually successful. 
A\'here there is some obstruction to the entrance of air in the trachea 
the obstetrician may be called upon to catheterize the trachea and, 
rarely, to perform tracheotomy. The inseition of the tracheal cathe- 
ter can usually be effected without difficulty, the operator taking 
the precaution to secure a good light in the child's mouth and to 
place the child's head and neck in a favorable position. The head 
should be thrown backward, the tongue drawn forward, and care 
should be taken not to pass the catheter into the esophagus. Aspira- 
tion of mucus and blood from the trachea may be performed by attach- 
ing a piece of rubber tubing to the catheter and cautiously re- 
mo^'ing the retained material by a strong piston syringe. If it is 
desired to introduce air through the catheter, this may be done by 
a rubber bulb or by direct insufflation from the mouth of the 
operator. 

In practising tracheotomy upon the newborn the operator should 
avoid the enlarged thymus gland, wliich will bleed freely. The 
small size of the trachea may make the operation difficult, but the 
operator should take sufficient time to thoroughly expose the trachea 
before attempting to open it. A medium-sized mbber catheter will 
often be found to serve better than the silver tracheotomy tube. 

Bibliography 
Ahlfeld: Zeitschrift f. rieburtshiilfe und C'.ynakologie. Band 56. Heft 3, 

1905. 
Beneke: Mimchener med Wochens., p. 1754, 1907. 
Beumer: Arztl. Sachverstandigenztg., Band 13. p. 407. 1!I07. 

441 



442 OPERATIVE OBSTETRICS 

Biasotti: Arch. Ital. di Ginecologia. Band 10. Pan 2. p. 113. 1907. 

Bliunm: Zentralblatt f. Gynakolcgie. Xo. 31. 1907. 

Gaszynski: Zentralblatt f. Gynakologie. Xo. 29. 1905. 

Kathe: BerKner klin. Wochens., Band 44. p. 1099, 1907. 

Malim: British Medical Journal, p. 1363. 1907. 

Marx: American Joiunal of Obstetrics, p. 555, 1907. 

Mochca: Ai'ch. di Farmacol sperin. Band 5, Hefts 1 and 2. 1907. 

Offergeld: Zentralblatt f. G^Tiakologie. Xo. 52. 1906. 

Rabe: Gaz. des Hop.. Xo. 143. 1906. 

Richter: Zentralblatt f. G^-nakologie. Xo. 31. 1907. 

Schmidt: Ina tig. -Diss.. Freiburg. 1905. 

Schultze: Zeitschrift f. Geburtshiilfe tmd GATiakologie. Band 57. Heft 1, 

l':€5. 

Seitz: Zentralblatt f. Gr^Tiakologie. Xo. 31. 1907. 
Teuli'el: Zentralblatt f. G^makologie. Xo. 31. 1907. 
Washboum: British Medical Journal, p. 1776. 1907. 
Weu': Glasgow MecUcal Jotu'nal. July, 1907. 
Wicke: Inausr.-Diss.. Miinchen. 1906. 



UMBILICAL HEMORRHAGE 

Hemorrhage may occur from the umbihcus of the newborn, from 
womids in the umbilical vessels, or from a disordered state of the 
infam's blooil. In the former, bleeding is controUed by pa.ssing two 
pins or large neetlles at right angles beneath the vessels, and then 
acljtisting a figtire-of-eight hgattire alx)ut the neenlles. The operator 
may prefer to expose the vessels and Hgate them indi^-idually. To 
avoid infection it is well to ligate the vessels in addition, as near the 
tip as possil-^le. ^ith veiy fine catgut or silk. Pressiu'e should be 
made over the umbihcus with a firm pad of gauze. 

If umbihcal hemorrhage results from the infected condition of 
the blood, surgical methods to check the hemorrhage wiU be useless, 
for this disorganizal blood will ooze through the vessels, and umbihcal 
hemorrhage is accompanied in these cases by hemorrliage into the 
intestines, into the bronchial tubes, the parenchyma of the limgs, 
and other viscera. Subcutaneous hemorrhage occurs in petechial 
spots and but few of these patients recover. Such cases are the 
result of infection usually developing in the intestines, an! in the 



UMBILICAL HERNIA 443 

exporitMUH^ of {he \\v\ivv the most efficient treatiiuMit consists in tlior- 
ongh irrigation of the large intestine with normal salt solution. 

Bibliography 

Chirie: Bull, de la Soc. d'Obstetr. de Paris, No. 10, p. 27S, 1907. 
Durante: Bull, de la Soc. d'Obstet. de Paris, No. 10, p. 303, 1907. 
Evicke: Zeitsclirift f. Gebui-tshiilfe und Gynakologie, Band 63, Heft 3, 

1909. 
Frank: Monatsschrift f. Geburtshiilfe und Gynakologie, Band 22, Heft 

4, 1905. 
Greiffenberg: Inaug.-Diss., Halle, 1906. 
Hass: Inaug.-Diss., Heidelberg, 1906. 

Holzapfel: Mimcliener med. Wochens., No. 54, p. 1751, 1907. 
Jens: Ugeskr. f. Laeger., No. 68, p. 673, 1907. 
Keller: Zeitsclirift f. Geburtshiilfe und Gynakologie, Band 58, Heft 3, 

1906. 
Knopfelmacher: Zentralblatt f. inn. Med., Band 28, p. 314, 1907; Wiener 

med. Presse, No. 48, p. 693, 1907. 
Lovrich: Zentralblatt f. Gynakologie, No. 31. 1907. 
Rousseau: These de Lyon, 1906. 

Salge: Deutsche med. Wochens., No. 33, p. 663, 1907. 
Shukowski: St. Petersburg med. Wochens., No. 32, 1907. 
Stern: Inaug.-Diss., Freiburg, 1907. 
Stumpf : Inaug.-Diss., Miinchen, 1907. 
Torday: Pester med.-Chir. Presse, No. 43, p. 685, 1907. 
Werkmesiter: Inaug.-Diss., Greifswald, 1906. 

UMBILICAL HERNIA 
While ordinary slight protrusion of the stump of the umbilical 
cord requires only the patient application of a pad and bandage, in 
some cases there is congenital lack of tissue, and operative treatment 
is indicated. If possible this should be done without anesthesia, 
as newborn infants bear anesthesia badly. The sac should be dis- 
sected out and its edges brought accurately together by continuous 
fine catgut sutures. Some operators prefer to use fine silk for this 
purpose. The fascia and skin are closed accurately and a gauze 
dressing applied with a snugly fitting abdominal bandage. Opera- 
tion in these cases is usually successful. 



444 



OPERATIVE OBSTETRICS 



THE SURGICAL TREATMENT OF FRACTURES IN THE NEWBORN 

After a difficult labor with severe birth pressure the child may 
be born with a fracture of the cranial vault. Should this be depressed, 
operation is indicated and will often prove successful. The scalp 
should be incised over the point of fracture and the bony fragments 
cautiously brought into their normal position as nearly as possible. 
If the dura mater be found to be injured the retained blood-clot should 
be gentty removed and the edges of the dura mater brought together 
with fine catgut. If oozing be present a very small strand of gauze 





Fig. 248. 



Fig. 249. 



Figs. 248 and 249. — Indentation of skull removed by operation (Kerr). 

may be left in the lower angle of the wound as a drain, or a few strands 
of silkworm gut may be laid at the bottom of the wound. 

Unfortunately, cases of difficult birth with cranial fracture often 
result in rupture of cranial vessels, producing hemorrhage into the 
substance of the brain. If such be considerable, the raising of depressed 
portions of bone will not be followed by much improvement, and 
the child will perish as a result of the intracranial bleeding. 

Fractures of the Upper Extreraities. — Fractures of the clavicle 



THE SrKGICAL TIUOATMENT OF FUACTl' RES I\ THE XEWIJOHN 445 

are not uncoinniou (luring labor in chiklnMi whose shoulders are much 
above the average and with whom delivery is artificially accom- 
plished. Such fractures are connnonly greenstick in variety, com- 
plete fracture being exceedingly rare. There is distinct mobility 
with displacement of fragments at the site of injury, and the contour 
of the shoulder is altered. 

To keep such fragments in apposition the chikl may be placed on 





li^. 



4 



Fig. 250. — Skiagram of infant born after difficult delivery, showing absence of frac- 
ture and dislocation. 



its back upon a firm pillow. If it can be maintained in this position 
the fragments will come into apposition without difficulty. As this 
may be difficult, the child may be bandaged upon the pillow by a 
broad figure-of-eight flannel bandage passed over the site of frac- 
ture and also encircling the opposite shoulder. 

In a case of double fracture of the clavicle occurring in the prac- 
tice of Dr. George A. Ulrich, Demonstrator of Obstetrics in the Jeffer- 



446 



OPERATIVE OBSTETRICS 





Fig. 251. — Fracture of arm following difficult delivery by version. 

son Medical College, the fracture was treated by placing the infant 
on a padded narrow board, 24 inches long and 7 inches wide. Across 
this was placed a narrow piece, one-quarter of the distance from the 



n%- '^1 




Fig. 252.— Greenstick fracture following difficult deliveiy; breech extraction. 



THE SURGICAL TKEATMEXT OF FRACTUllES IN THE XKWBOHX 447 

top, ami tirinly fa.^tenecl. The chikl's arms were carried upward, 
absorbent cotton placed between the arms and the sides of the body- 
to avoid bringing the skin surfaces together, and the arms were band- 
agal to the sides. A hrm pad was inserted between the shoulders and 






Fi?. 253.— C 



alius 

the 



formed in fracture of 
humerus. 



Fig:. 254. — Fracture of both 
difficult binh. Mode of 



clavicles in 
dressinor. 



over each clavicle This apparatus remained upon the child for 
eighteen days, and upon its removal perfect union had result al. 

Fractures of the humerus may occur during difficult version and 
extraction, in bringing down the arms. Fracture of the humerus 



448 



OPERATIVE OBSTETRICS 



may also develop in spontaneous birth with vertex presentation if 
the arm prolapses beside the head. In treating these cases a splint 
of soft pasteboard or spongiopiline covered with cotton and gauze may 
be fitted over the fracture and kept in place by gauze bandages. 
The splints should be frequently removed, as callus speedily forms, 
and care should be taken not to exercise undue pressure upon the 
tissues. As soon as callus forms the sphnt should be discarded and 
the child allowed to move the arm freely. 




Fig. 255. — Complete fracture of the humerus in difficult extraction, with craniotomy. 



Fractures of the femur, though rare, may occur in difficult version 
and extraction. A good result is usually obtained by the use of splints 
only, without extension; but should evident shortening develop, the 
child may be bandaged upon a pillow and extension applied. 

In the WTiter's experience serious deformity has not followed this 
accident. 

Bibliography 

Brewitt: Zentralblatt f. Gynakologie, No. 13, 1908. 

Couvelaire: Annales de Gyn., Second Series, No. 4, 1907. 

Favre: Inaug.-Diss., Konigsburg, 1906. 

Groeschel: Inaug.-Diss., Breslau, 1907. 

Grossgebauer : Inaug.-Diss., Bonn, 1906. 

Hofbauer: Zentralblatt f. Gynakologie, No. 31, 1907. 



SURGICAL TREATMENT OF liHAC'HIAL PALSY IX THK NEWBORN 449 

Isnielowitz : Inaug.-Diss., Basle, 1906. 

Jolly: Zentralblatt f. Clynakologie, Xo. 31, 1907. 

Jones: British Medical Journal, June 6, 190S. 

Katzmann: Inaug.-Diss., Freiburg, 1907. 

Lotheissen: Wiener med. Wochens., No. 57, p. 2274, ]9()7. 

Pottier: These de Paris, Xo. 44, Band 7, 1900. 

Riemann: Zentralblatt f. Gynakologie, X^o. 31, 1907. 

Scheib: Verhandl. d. Deutschen Gesellsch. f. Gj-n., 12. Kongress, p. 
295, 1907. 

Schiff : Zentralblatt f. Gynakologie, No. 49, 1905. 

Seitz: Archiv f. Gynakologie, Band 82, p. 529, 1907; Archiv f. Gyna- 
kologie, Band 83, p. 701, 1907; Zentralblatt f. Gynakologie, No. 
31, 1907; Yerh. d. deutsch. Ges. f. Gyn., 12, Kongr., p. 416, 
1907. 

Stuhl: Deutsche med. Wochens., X'o. 33, p. 103, 1907. 

Veit: Zentralblatt f. Gynakologie, Xo. 31, 1907. 

THE SURGICAL TREATMENT OF BRACHIAL PALSY IN THE NEW- 
BORN 

Injuries to the brachial plexus may result from violent and rapid 
delivery of the child, the head presenting after the birth of the arm, 




Fig. 256. Fig. 257. 

Figs. 256 and 257. — Paralysis of upper extremity after difficult birth, cured by 

operation. 
29 



450 



OPERATIVE OBSTETRICS 



or when difficulty is experienced in bringing down the shoulders. In 
cases of breech labor with extraction, if the arms become extended 
above the head and must be forcibh^ brought down, injury may also 
occur. The condition is recognized by loss of motion on the affected 
side, with gradual atrophy and alterations in the temperature. If the 





W ■ 

Fig. 258. — Skiagram of infant's body. Difficult delivery. Paresis of left upper 
extremity, showing tlie absence of fracture. 



brachial plexus be exposed, the loops of the fourth, fifth, and sixth 
cervical nerves are found most commonly affected. Occasionally 
the sternocleidomastoid muscle is also injured. In some cases of 
fracture of the clavicle and fracture of the humerus a resulting callus 
has produced injury to the brachial plexus. Separation of the epiph- 



SURCICAL THKATMKXT OF BKA(1I1A1. PALSY 1\ THK XKWJiOKN 4")! 

Ysis may also ho \nv^vut. Stalpc^'^ foiiiul that actual lacci-ation 
of {\\o norvo-Hbcrs is (^x('oo(lin,a;ly rare. Tlu^ coiuuH'tivc* tissue sur- 
rounding the nerves is oftc^n lacerated and callus of connective tissue 





a 



Fig. 259. — Skiagram of infant's body. Difficult delivery. Paresis of left upper 
extremity, showing the absence of fracture. 

forms which compresses and injures the nerve-trunks. AVhere 
spontaneous labor is unduly prolonged, cerebral compression may 
result in injury to the motor centers supplying the upper limbs. 

1 Monatsschrift f. GeburtshiiKe und Gynakologie, Band 14, p. 14, 1901. 



452 OPERATIVE OBSTETRICS 

In many cases injuries to the brachial plexus do well when treated 
by splintS; by massage, and the galvanic current. The injured extrem- 




Fig. 260. — Skiagram of infant's body. Difficult delive^J^ Paresis of left upper 
extremity, showing the absence of fracture. 



ity must be kept warm. If tendency to contraction develops, a splint 
should be fitted. Kennedy/ Clark, Taylor, and Prout - have secured 

1 British Medical Journal, vol. 1, p. 298, 1903, and No. 2286, p. 1065, 1904. 
^ American Journal of the Medical Sciences, p. 670, October, 1905. 



IX.URIES TO THK SCALP 453 

good results when t'ontraction (lovoloixnl by cutting down ui)()n the 
brachial plexus, isolating injured nerves, freeing them from sur- 
rounding adhesions, excising the thickened trunks, and suturing the 
severeil ends with fine catgut. This operation is best performed 
when the child is several months old. 

• 

BlBLIOGRAPHY 

Bullard: American Journal of the Medical Sciences, Xo. 134, p. 93, 

1907. 
Engelhard: Inaug.-Diss.. Utrecht, 1907. 
Jeannin: Zentralblatt f. Gynakologie, Xo. 32, 1907. 
Kilvington: Zentralblatt f. Chir., X^o. 34, 1907. 
Magne: These de Paris, Xo. 42, 1906 and 1907. 
Prout : Journal of the American Medical Association, Xo. 4S, p. 103, 

1907. 
Seitz: Miincliener med. AVochens., Xo. 54, 1907. 
Steffen: Zentralblatt f. Gynakologie, Xo. 31, 1907. 
Taylor: Journal of the .American Medical Association, January 12, 1907, 

and Xo. 48, p. 96, 1907. 
Thibonneau: These de Paris. Xo. 7, 1906 and 1907. 
Warrington and Jones: Lancet, December 15, 1906 

INJURIES TO THE SCALP 

Injuries to the fetal scalp received during labor are usually con- 
tused wounds which rarely require suture. Should hemorrhage 
occur from vessels which can be isolated, they may be tied, or if the 
vessels cannot be secured, a curved needle armed with fine catgut 
should be passed deeply beneath the bleeding area, and hemorrhage 
thus controlled by pressure. Antiseptic solutions, with the exception 
of boric acid, should not be applied to wounds upon the newborn 
child because of the danger of absorption and poisoning. Contused 
wounds may be powdered with boric acid or with a sterile substance, 
such as baked starch, and the powder allowed to form a protective 
crust or covering. Where surgical dressings are necessary, sterile 
gauze may be retained in position by a skullcap or by zinc oxid 
adhesive plaster. 



454 



opeeati\t: obstetkics 



Cephalhematoma. — This common mjiir}' to the scalp and craniimi 
is often accompanied by bruising or laceration of the stemocleido- 




Fig. 261. — Cephalhematoma. 

mastoid muscle. In both cases the lesion is essentially an extrava- 
sation of blood with niptiu*e of capillaries^ injm^' to connective tissue^ 




Fig. 262. — Cephalhematoma. 

and in the cranial injiir\^ bruising of the periosteum, and sometimes 
separation over a considerable area. 



IXJUHIES TO THK SCALP 



455 



This injury develops in cases where the resistance of the mother's 
tissues has causeil unusual pressure, or where premature rupture of 






Fig. 263. — Compression of the fetal head in the biparietal diameter in a patient who 
had strong labor-pains before deliveiy In- section. 

the membranes or the use of forceps have comi^licated labor. By 
some an abnormal growth of hair upon the cliild's head has been 



456 OPERATIVE OBSTETRICS 

considered a predisposing cause. The injury has also been observed 
after spontaneous labor without complications, in wliich its cause 
could not be detected. 

^Yhen blood accumulates beneath the periosteum upon the internal 
surface of the cranial bones it forms internal hematoma. This can 
be diagnosticated only by pressure symptoms, which gradually 
develop. 

In cases where the head is strongly twisted to one side and a con- 
siderable pressure is exerted upon the neck, hematoma of the sterno- 
cleidomastoid muscle may develop. The tumor is found in the belly 
of the muscle and may become distinctly hard and painful upon 
pressure. The muscle itself is sometimes torn and its sheath infil- 
trated. 

Torticollis may be congenital, developing within the, uterus 
from pressure, usualty the result of some comphcated position or 
presentation. This causes pressure upon the blood-vessels, resulting 
in atrophy with interstitial myositis. 

Treatment. — In treating hematoma of the cranium or sternocleido- 
mastoid muscle the operator must await the formation of a definite 
tumor and its limitations by inflammation. Usually these cases do 
not require incision and drainage. The skin should be carefully 
cleansed and a protective dressing of sterile gauze should be w^orn. 
Should the clot become softened and absorption be unduly prolonged, 
it may be incised, the clot removed, and the torn vessels isolated 
and tied. The cavity of the clot sliould be firmly packed with sterile 
gauze. This packing should be renewed with irrigation with salt 
solution until the cavity is obliterated. 

In dealing with congenital torticolUs, as soon as the cliild's general 
vigor has become estabfished such operation as is. indicated in this 
condition may be performed. 

LESIONS OF THE FACE AND THE ORGANS OF SPECIAL SENSE 

In addition to contused wounds upon the face, the newborn child 
may present malformations which should receive attention even in 



LESIONS OF THE FACK AND TIIF ORGANS OF SIMOCIAL SENSE 457 

the first weeks of life. Hare-lip and cleft palate, if extensive, cannot 
be operated upon at once, but something can be done to bring together 
the gaping paits by daily pressure. The physician, or the nurse in 
his absence, should apply the fingers firmly against the maxillary 
bones and make hrm pressure directly toward the central line of the 
cranium several times daily. In the experience of the writer a per- 
ceptible gain has followed this simple procedure. 

Hare-lip may be operated upon as soon as the child is vigorous 
enough to bear moderate blood loss. Deep anesthesia should be 







Fig. 264. — Head of child bruised by ineffectual attempts at forceps deliA-ery. 
Mother deUvered by Porro operation. The child sun'ived, with loss of sight in the 
bruised eye. 



avoided, and the operation, if possible, performed without anes- 
thesia. The more extensive operation upon the palate must be 
deferred until the child is older. 

Injuries to the Ear. — In unskilful delivery by forceps or in violent 
and forcible extraction the ear of the child may be wholly or partially 
severed. The internal ear will be injured if the pressure has been 
severe, the cranial bones will be fractured, and the scalp considerably 
lacerated. If such injuries are extensive a fatal result will soon 
follow. Where the child's condition justifies it, lacerations should 



458 OPERATIVE OBSTETRICS 

be promptly repaired with fine sterile catgut. Mastoid injury, should 
infection follow, must be treated by early drainage. 

Injuries to the Eye. — Long-continued pressure frequently causes 
hemorrhage into the retina and extravasation of blood into the 
chambers of the eye. In some cases these injuries are accompanied 
by fractures of the cranial bones. Unsuccessful attempts at forceps 
delivery may rupture some of the coats of the eye, ruining its refrac- 
tive media. That such injuries are not infrequent is shown by 
Paul.^ In 200 newborn infants there was retinal hemorrhage in 50 
per cent, of those born through contracted pelves. In spontaneous 
birth the same lesion was observed in 40 per cent. Where labor 
was complicated and severe, without pelvic contraction, hemorrhage 
into the retina occurred spontaneously, and there was retinal bleeding 
of variable extent in one-fifth of the cases. Should the child be born 
with a dislocated eye, forced from its socket by severe pressure, the 
eyeball should be immediately replaced and the eye bandaged with 
gauze saturated with boric acid solution or sterile salt solution. 
An ophthalmologist should be summoned to such cases as soon as 
possible. 

Bibliography of Injuries to the Head and Face in the 

Newborn 
Brav: New York Medical Journal, No. 86, p. 499, 1907. 
Bugge: Zentralblatt f. Gynakologie, No. 32, 1907. 
Doring: Zentralblatt f. Chirurgie, No. 34, 1907. 
Ginzburg: Inaug.-Diss., Berlin, 1907. 

Heinlein: Miinchener med. Wochens., No. 54, p. 2619, 1907. 
Peters: Archiv f. Augenhlkde., Band 56, Heft 4, 1907. 
von Sicherer: Deutsche med. Wochens., No. 33, p. 1564, 1907. 

CONGENITAL LACK OF DEVELOPMENT 

In the diagnosis of fractures, dislocations, and other injuries to 
the bones of the newborn care must be taken not to mistake mal- 
formations and lack of development for recent injuries. Sperling^ 
found by examining fetal bones with the a:-ray and microscope that 

^ Inaugural Dissertation, Halle, 1900. 

2 Zeitschrift f. Geburtshulfe und Gynakologie, Band 26, p. 1134, 1902. 



THE SURGICAL TREATMENT OF INFECTION IN THE NEWBORN 459 

many cases of supposed fracture were con^^enital lack of (levelo[)- 
ment. The most freciueiit cause of these conditions was adhesions 
in the amnion occurring during the first and second months in the 
development of the embryo. Periostitis with infiltration by small 
cells is the lesion usually present, without bending of the bones or 
callus. In GO per cent, of cases which had been diagnosticated as 
fractures occurring in the uterus, congenital malformation was found 
to be the lesion present. The most striking example of this is seen 
in congenital deformity and dislocation of the hip-joint. 

Such cases are rarely suitable for surgical treatment until the 
child has passed several years of life. The surgeon may then choose 
between Lorenz's method in cases of dislocation of the hip-joint or 
the open method by incision practised extensively by Hoffa. 

Bibliography 
Forbes and Russell: Montreal Medical Journal, December, 1906. 
Gilbert: Gaz. des Hop., No. 80, p. 1578, 1907. 
Hamburger: Deutsche med. Wochens., No. 33, 1907. 
Kraemer: Wiener klin. Wochens., No. 20, 1907. 
Lett: The Lancet, vol. 1, p. 1365, 1907. 

Martin: Surgery, Gynecology, and Obstetrics, September, 1908. 
Maxwell: Transactions Obstetrical Society of London, No. 48, p. 277, 

1907. 
Schmidt: Inaug.-Diss., Freiburg, 1905. 
Schiiller: Deutsche med. Wochens., No. 33, 1907. 
Stratz: Zeitschrift f. Geburtshiilfe und Gynakologie, Band 65, Heft 1, 

1909. 

THE SURGICAL TREATMENT OF INFECTION IN THE NEWBORN 

The umbilicus is the point of entrance of infection in the majority 
of cases in newborn children. This is frequently accompanied by 
wounds or abnormalities in the umbilical vessels, and is usually 
preceded by umbilical hernia. The umbilicus does not normally 
close and there remains an open granulating surface through which 
infection readily enters. In some cases an umbilical fungous growth 
develops which bleeds on contact. 

In treating these conditions, umbilical hemorrhage must be pre- 



460 OPERATIVE OBSTETRICS 

vented as far as possible and prompth' controlled. Fungous growths 
of the umbilicus may be ligated or destroj^ed by the actual cauterv'. 
Should infection be present, but little can be done surgicaUy to limit 
its extent. The umbilical surface may be cleansed thoroughly with 
salt solution and sterile dressings applied. Should persistent oozing 
of dark fluid blood occur, it is a sjTnptom that the blood has become 
extensively infected and a fatal termination usually foUows. 

BiBLIOGKAPHT 

AUan: Z " latt f. Gynakologie, Xo. 31, 1907. 

Aps: I:i: :g -L'^5., Tubingen, 1907. 

C - :ier de Ribes: Zentralblatt f. Gynakologie, Xo. 31, 1907. 

Ciiiari: Deutsche med. Wochens.. Xo. 33, 1907. 

Komak: Bulletin of the Lying-in Hospital, Xew York. March, 1908. 

Schubert: Zentralblatt f. G3rnakologie, Xo. 7, 1907. 

Stumpf ; Inaug.-Diss., Munchen, 19G7. 

ORCoiasiox 

The traditional eight days for the performance of this opera- 
tion may be selected by the obstetrician if the religious views of 
the parents of the child suggest its election. If not, any conve- 
nient time during the first month or six weeks may be chosen. In 
newborn children anesthesia is contraindicated, as the operation can 
be done more safely without it, and the child suffers but little dis- 
turbance and inconvenience. In cases which seem to promise the 
aA oidance of the operation the prepuce should be thoroughly dilated 
and retracted and adhesions separated by a blunt-pointed probe. 
Sterile olive oil should be freely applied to prevent the adhesions 
from re-forming. If the child be under the care of an intelligent 
nurse this simple procedure wiU often be sufficient. 

In cases where there is great contraction or where dilation is fol- 
lowed by but temporary relief, circumcision gives the only promise 
of success. 

In performing the operation the obstetrician must be careful to 
secure sufficient assistance to completely control the child. The 



CmCCMCLSION 401 

infant shoukl be placetl upon a small table suitably packletl ami in 
a goocl light. One assistant is recjuirecl to control the arms alone in 
active, ^'igo^ous chiltiren where the operation is done some weeks after 
birth. In smaller children an experienced nurse can control the lower 
extremities and practically the upper as well. A clean handkerchief 
dipped in cool water may be introduced into the mouth so that the 
chikl can suck upon it during the operation. 

The parts should be thoroughly cleansed with clean soap and 
sterile water and with boric acid solution. It Is well to take a time 
when the infant has not been fed, thus preventing vomiting after the 
operation, and keeping the bottle as a sedative in quieting the chiil. 
A reliable surgical assistant is necessary in addition to one or two 
nurses. 

The tip of the prepuce is seized by hemostatic forceps and drawn 
gently outward, and a guard, composed of the handles of a pair of 
small scissors or any other suitable appliance, is placed in front of 
the penis, compressing the prepuce. The incision shoukl be slightly 
oblique from above, downward and outward. The redundant skin 
shoukl be severed with blunt-pointed sharp seizors A knife shoull 
not be use»l. as a sudden motion of the chikUs limbs escaping the grasp 
of the nurse might result in an incised wound of considerable severity. 
The severetl tissues should be allowed to retract, and oozing tempo- 
rarily checked by the application of sterile sponges. The inner layer 
shoukl then be thoroughly separated by a blunt-pointed probe or 
director, and incised sufficiently in the median line above to permit 
its free retraction. Retained secretions should be sponged away with 
sterile water. Sufficient of the inner layer shoukl then be trimmed 
away to permit approximation with the skin e«:lges. a sufficient flap, 
if possible, being left to cover the corona. 

In the writer's experience this is desirable, and residts in less irri- 
tation than if the tissues are trimmed to such an extent that the corona 
b left exposed. Care should be taken not to cut upon the dorsal 
aspect too far. lest the dorsal artery or vein be wounded. The obstet- 
rician must also take care that the tissues are sufficientlv incised to 



462 OPERATIVE OBSTETRICS 

permit free retraction without the formation of a constricting band 
when the tissues heal. 

In the writer's experience good results have followed the ligation of 
the frenulum by a stitch passed from above downward by two needles 
threaded with the same fine catgut suture. These two needles are 
inserted one on each side of the median hue, joining the mucous and 
cutaneous surfaces, and the ends are tied below upon the skin sur- 
faces. This sufficiently secures the vessels and prevents hemorrhage. 
Several additional stitches of fine sterile catgut are taken upon the 
upper surfaces, bringing the mucous and cutaneous edges in apposition. 
The operator must see to it that the dorsal vessels do not bleed and 
are properly secured. When oozing has ceased, a probe dipped in 
sterile ohve oil should be apphed to the coronal region, thus prevent- 
ing the re-formation of adhesions. 

If fine sterile catgut has been used it is not necessary to remove 
the stitches, as they will be absorbed during the first week. A nar- 
row strip of iodoform gauze should be applied about the junction of 
the severed edges and allowed to remain in place from twenty-four 
to thirty-six hours. This prevents oozing and infection. The 
parts should be covered with sterile gauze upon which is placed an 
ointment of 10 per cent, boric acid, and the dressing retained in. 
position by a T-bandage. AAlien urination occurs the gauze should 
be renewed, and, if necessary, the parts cleansed with boric acid 
solution or sterile water. Thirty-six hours after the operation the 
cliild may be placed in a large basin with warm sterile water and the 
iodoform gauze gently soaked off. This warm bath may be repeated 
daily to advantage. During convalescence the parts should be pro- 
tected by sterile gauze and the boric ointment apphecl liberally to 
prevent re-formation of adhesions a.nd irritation from the dressings. 
Convalescence is usually complete in a w^eek or ten days. 

The comphcations attending circumcision in infants are hemor- 
rhage, the re-formation of adhesions, and the growi-h of scar tissue, 
defeating the purpose of the operation. Hemorrhage should be effi- 
ciently prevented by a ligature, if necessary, but stitches rarely fail 



(MIKTMCISION 4()3 

to pivvtnit or control blcH^ding. If bkHMliii*;- points must he tied, lino 
catgut should be selected. Should oozing be excessive, the nurse 
should be instructed to make pressure with a pad of gauze and a T-band- 
age. Infection is prevented by asej)tic precautions, which should be 
strictly carried out. In thirty-six to forty-eight hours the edges of 
the wound are sufficiently united to i)revent infection under favorable 
conditions. Occasionally in children who are not undc^r good control 
injuries may occur b}' bruising followed by considerable swelling. In 
other cases marked swelling develops, with infiltration of the tissues 
by serum, which subsides without injury under aseptic care. In the 
hands of an experienced operator, under aseptic precautions, the 
operation gives good results, and shoukl be promptly performed 
unless dilation proves thoroughly efficient. 

If the child be excessively restless and fretful a small dose of 
paregoric, 3 to 5 drops, may be given, with 10 drops of brandy. Usu- 
ally within an hour after the operation the child will take one-half 
or two-thirds its usual nourishment eagerly and will drop asleep. 
If it be excessively restless, bromid of sodium, in 1 or 2 gr. doses, 
may be given as necessary. In cases where urination has been pro- 
longed and difficult the child often experiences marked relief after 
the operation, and within a few days is noticeably more comfortable 

and quiet. 

Bibliography 

Bland-Sutton: British Medical Journal, Xo. 1, p. 1409, 1907. 

Churchward: British Medical Journal, Xo. 2, p. 51, 1907. 

Dampier-Bennett : British Medical Journal, No. 2, p. 243, 1907. 

Deutsch: Orvosi Hetilap., Xo. 45, 1906. 

Ecler: British Medical Journal, Xo. 2, p. 117, 1907. 

Gallant: International Clinic, Philadelphia, 1907. 



NDEX 



A B DOM EX, closure of, after celioh\'^sterot- 
omy, 307, 309 
during pregnancy, 23 
Abdominal aorta, compression, in post- 
partum hemorrhage, 380 
dressing after celiohysterotomy, 308, 
309 
in celiohysterectomy, 318 
pregnancy, operation in, 108 
section, deliver}^ by. 300 
methods, 300 
in pregnancy, 99 
in rupture of uterus, 329 
results, 327 
with sterilization, 314 
wall, relaxation, after labor, correction, 
422 
Abortion, therapeutic, 66 
anesthetic for, 67 
technic of, 67 
Abscess, multiple, complicating puerperal 
state, 434 
of breast in newborn, 439 

puerperal, 436 
pelvic, Pryor's treatment, 431 

surgical treatment, 430 
stitch-hole, after celiohysterotomy, 314 
Accouchement force, 71, 89 
Acetonemia after anesthesia, 36, 37 
Achondroplasia, 318 
Acid, boric, 41 
carbohc, 41 
Acidosis after anesthesia, 36 
Adherent placenta, removal of, 366, 367 
Adrenalin in postpartum hemorrhage, 379 
After-coming head, delivery of, by for- 
ceps, 153 
manual method, 149 
Amniotic fluid, escape of, into abdominal 

ca\'ity, in celiohysterotomy, 310 
Amputation of fetal parts to effect 
delivery, 253 
30 



Anatomy, 17 
Anesthesia, 29, 35 

acetonemia after, 36, 37 

acidosis after, 36 

by lumbar injection, 33 

with eucain-adrenalin, 35 
with scopolamin morphin, 34, 35 
with stovain, 34 
chloroform, 32 
complications after, 36 
effect of, on fetus, 35 
ether, 30 

bronchitis after, 36 
pneumonia after, 36 
ethyl chlorid, 30 

heart failure during, treatment, 37 
in forceps delivery, 183 
in version, 213, 222 
nitrous oxid, 30 
recovery from, 33 
spinal, 33 

summary of results, 35 
Anesthetizer, 29 
Anteflexion of uterus, 51 

in pregnancy, 18 
Anteroposterior diameter of pelvic inlet, 
internal measurement, 72, 73 
outlet, measurement, 70 
Anteversion of uterus after labor, cor- 
rection, 419 
Antiseptic fluids, 41 

bichlorid of mercury, 41 
boric acid, 41 
carbolic acid, 41 
formalin, 41 
lysol, 41 
Aorta, abdominal, compression of. in 

postpartum hemorrhage, 380 
Appendicitis in pregnancy, operation for, 

93 
Appendix, vermiform, in pregnancy, 24, 
93 

465 



466 



IXDEX 



ArgATol in ophthalmia neonatorum. 41 
Arm. fetal, manual delivery through 

vagina. 135 
Asepsis of birth-canal, 24 
of nipples. 41 
of operator, 42 
Asph\-xia in newborn, 441 
Assistants for obstetric operations. 49 
Auvard's cranioclast, 243 
Ajds-traction forceps. 165 
apphcation, 165 
Poulet's tapes with. 167 
Tamier's. 167 

Bacillus coli communis, pyelitis from 

infection by, in pregnancy, 97 
Bacteria in birth-canal, 24 
Bag, de Ribes', SI 

dilating, and bougies, induction of 
labor by means of, 7S, SI 
for dilation of cervix, 90 
in placenta prsB^-ia, 391 
sterilization of, 40 
Bandage, ]Mombiu-g's, in placental sepa- 
ration, 399 
Basiotripsy, 247 

Baumm's method of pubiotomy. 273 
Bed, selection of. in private house, 46 
Bichlorid of mercury, 41 
Bipolar version, 221, 222, 223, 225 
Birth-canal. See Genital tract. 
Bladder during and after labor, 23 
fetal bones in. Ill 
injury to. in pubiotomy. 272 
irritation of, in ectopic pregnancy, 110 
woimding of. in celiohysterotomy, 310 
Bones, cranial, fractures of, from forcei)S, 
202 
fetal, in bladder. Ill 
Bony union after pubiotomy. failure of, 

2S2 
Boric acid. 41 

Bossi's dilator for dilarion of uterus, S9 
Bougies, induction of labor by means of, 
76 
dilating bags with. 7S. SI 
technic, 79 
sterilization of. 40 
Brachial palsy in newborn, surgical treat- 
ment, 449 
Braun's cranioclast. 244 



Braim's hook. 253 

Braxton-Hicks' method of version. 215 

treatment of placenta prae\-ia, 391 
Breast, abscess of, in new-bom, 439 

puerperal, 436 
Breech dehvery, engagement in. 122 
manual method, 136 
comphcations, 159 
with premature fetus, 161 
version in, 226 
Bronchitis after ether anesthesia, 36 
Brow presentation, engagement in, 121, 

123 
Bunmi's method of pubiotomy, 271,. 



Carbolic acid, 41 
Carcinoma of uterus, 59 
Cecum, position of, in pregnancy. 93 
Cehohysterectomy with extraperitoneal 
treatment of stump, 320 
chart of blood-pressure during,. 

324 
comphcations, 325 
hemorrhage in, control, S25 
indications, 320 
recovery from, 323 
technic, 321 
with intrapel\-ic treatment of stump, 
315 
abdominal dressing, 3 IS 
after-care of patient, 318 
comphcations, 320 
control of hemorrhage. 316 
indications. 315 
puerperal period after, 3 IS 
results, 320 
technic, 315 
Cehohysterotomy, 301 
abdomen closed. 307, 309 
abdominal dressing, 30S, 309 
after-care of patient, 311 
apphcation of forceps after, 194 
bladder in. wounding of. 310 
care of child after. 312 
closing uterine inci-^ion. 305, 307 
comphcations after. 313 
comphcations during. 310 
dehvery of child, 303, 306 
dilarion of intestine after, 31S 
of stomach after. 313 



IXDKX 



4(r 



Celiohystcrotomy, oscapo of amniotic 
fluid into abdominal cavity in, 310 
of intestine in, 310 
forceps deliverj' after, 194 
general care of mother after, 313 
hemorrhage after, 313 
hemorrhage in, control of, 305 
in placenta pnevia, 391, 393, 396 
in suspected cases, 310 
incising uterus, 302, 305 
indications for, 301 
pouring salt solution into uterus, 304, 

307 
relaxed uterus in. 310 
removal of uterus from abdomen, 304 
septic infection after, 314 
stitch-hole abscess after, 314 
technic of, 303 
uterus closed and contracted, 306 

tiu-ned out of abdominal ca^dt}', 301 
vaginal, 2S9 

application of, 295 
compUcations after, 292 
for placenta prsevia, 294 
in vaginal dehvery, 2S9 
indications for, 291, 295 
technic of, 2S9 
version after, 229 
wounding bladder in. 310 
Cephalhematoma in newborn, 454 

surgical treatment, 456 
CephaUc version, 210 
Cephalotribe, 245, 246 
Cephalotripsy, 245 

Cervical section in placenta pr8e\-ia, 394 
Cervix, dilation of, in version, 236 

rapid and forcible, 89. See also 
Uterus, dilation of. 
incision of, 2vS7 
lacerations of, immediate repair, 402 

technic, 403 
section of vaginal extraction preceded 

by, 2S7 
torn, puerperal hemorrhage from, 385 
Cesarean section, 301. See also Celio- 
hystcrotomy. 
Child, care of, after celiohysterotomy, 
312 
in induced labor, >i6 
Chloroform anesthesia, 32 
Cholecystotomy in pregnancy, 96 



Circumcision in newborn, 460 

compUcations, 462 
Clavicle, fracture of, double, in new born, 
445 
in newborn, 444, 445 
Cleft palate in newborn, treatment, 457 
Cleidotomy, 134, 249 
Coccyx, injury to, from forceps, 202 
Conibined version, 210, 215. See also 

Version, combined. 
Comphcations of breech extraction, 159 
Confinement room, 45 
Contracted pelvis, appHcation of forceps 
in, 207 
irregularly, 127 
version in, results, 229 
Cornual pregnancy, operation in, 109 
Cranial bones, fractures of, from forceps, 

202 
Cranioclasis, 243 
Cranioclast, Auvard's, 243 

Braun's, 244 
Craniotomy, 240 
instruments for, 241 
mortality' of, 255 
Smelley's scissors for, 241 
unusual forms, 248 
Cranium, fracture of, in version, 233 
hematoma of, in newborn, 454, 456 
treatment, 456 
Cul-de-sac, vaginal, opening of, from 

forceps, 201 
Cyst, ovarian, 62, 63 

Decapitation. 253 

Deformity of fetus, induction of labor for, 

87 
Delivery after pubiotomy, 269 
breech, manual method, 136 
complications, 159 
with premature fetus, 161 
by abdominal section. 300 

methods, 300 
forceps, 163. See also Forceps delivery. 
of fetus through the vagina, 117 

after-coming head, by forceps, 

153 
condition of lower birth-canal 

as indicating, 126 
deformity in pelvic outlet in, 127 
determining engagement, 118 



468 



INDEX 



Delivery of fetus through the vagina, 
determining engagement, 
118 
inertia in, 125 
rupture of uterus in, 125 
indications, 117 
manual method, 130 

after-coming head, 149 

head, 130 

lower extremities and 

breech, 136 
presenting arm, 135 
shoulders, 132 

cleidotomy for, 134 
trunk and upper extremi- 
ties, 142 
vaginal, incision into pelvic floor and 
perineum in, 299 
of cervix in, 287 
preceded by enlargement of birth- 
canal, 257 
by section of cervix, 287 

of lower uterine segment, 287 
of perineum, 287 
vaginal Cesarean section in, 289 
De Ribes' bag, 81 

Detachment, premature, of normally im- 
planted placenta, 397. See also Pla- 
centa, separation of. 
Development, congenital lack of, in new- 
born, 458 
Diameter, anteroposterior, of pelvic out- 
let, measurement, 70 
transverse, of pelvic outlet, measure- 
ment, 71 
Diameters of fetal head, 77 
of pelvic excavation, 78 
inlet, 74 
outlet, 70 
Diastasis of recti muscles after labor, cor- 
rection, 422 
Dilating bags and bougies, induction of 
labor by means of, 78, 81 
for dilation of cervix, 90 
in placenta prsevia, 391, 393 
sterilization of, 40 
Dilation of cervix in version, 236 

of intestines after celiohysterotomy, 313 
of stomach after celiohysterotomy, 313 
rapid and forcible, of uterus, 89 
Bossi's dilator for, 89 



Dilation, rapid and forcible, of uterus, 
dilators for, 89 
elastic bags for, 90 
Harris's method, 90 
laceration during, 91, 92 
multiple incisions for, 90 
Newell's dilator for, 90 
Dilator, Bossi's, for dilation of uterus, 89 

Newell's, for dilation of uterus, 90 
Dislocation of eye in newborn, 458 

of spleen in pregnancy, 24 
Displacements of uterus, 51 

after labor, correction of, technic, 422 
cause, 51 

correction of, after labor, with or 
without lacerations, 419 
Doderlein's method of extraperitoneal 
section, 343-349 
of pubiotomy, 270 
Dressings, surgical, in private houses, 48 

Ear, injuries to, in newborn, 457 
Eclampsia, Edebohls' operation for, 98 
Ectopic pregnancy, irritation of bladder 
in, 110 
of rectum in, 110 
operation for, 100-112 
ruptured, operation in, 106, 107 
suppurating, 110, 111 
Edebohls' operation for eclampsia, 98 
Elastic bag in placenta prsevia, 391, 393 
Electricity in control of postpartum hem- 
orrhage, 381 
Embryotomy, 237 
frequency of, 254 

general considerations concerning, 240 
indications for, 238 
mortality of, 255 
results of, 254 
Emmet's operation for repair of lacera- 
tions of pelvic floor, 416 
Emptying uterus after viability and be- 
fore full term, 69 
before viability, 66 
Enlargement of birth canal, vaginal ex- 
traction preceded by, 257 
permanent, of pelvis, after pubiotomy, 
276 
Schickele's operation for, 282 
postural, 257 
Episiotomy, 299 



INDEX 



409 



Episiotomy in forceps delivery, 187 

wouiuls, closure of, 410 

Ether anesthesia, 30 

bronchitis after, 36 

pneumonia after, 36 

Ethyl chlorid anesthesia, 30 

Eucain-adrenalin anesthesia by lumbar 

injection, 35 
Evisceration, 251 
Exercise, influence of, on passage of child 

into pelvis, 260 
Extirpation, total, of pregnant womb, 330 
Extraction. See Delivery. 
Extraperitoneal section by inguinal in- 
cision, 341 
Doderlein's method, 343-349 
Frank's method, 343 
Jorg's method, 342 
Ritgen's method, 342 
Thomas' method, 342 
Extra-uterine pregnancy, 100. See also 

Ectopic pregnancy. 
Extremities, lower, and breech of fetus, 
manual method of vaginal delivery, 
136 
thrombophlebitis of, surgical treat- 
ment, 429 
upper, and trunk of fetus, manual 
method of vaginal delivery, 142 
fractures of, in newborn, 444 
Eye, dislocation of, in newborn, 458 
injuries to, in newborn, 458 

Face, abrasions of, from forceps, 202 
injuries to, in version, 233 
lesions of, in newborn, 456 
presentation, application of forceps in, 
172, 173, 174, 175 
engagement in, 123 
Facial paralysis from forceps, 202 
Fallopian tubes, operations on, 62 
Femur, fractures of, in newborn, 448 
Fetal bones in bladder. 111 
debris in rectum, 111 
head, diameters of, 77 
Fetus, abrasions of face in, from forceps, 
202 
deformity of, induction of labor for, 

87 
dehvery of, piecemeal, 254 
through vagina, 117 



Fetus, delivery of, through vagina, aft(T- 

coming head, by forceps, 153 

condition of lower birth-canal 

as indicating, 126 
deformity in pelvic outlet in, 127 
determining engagement, 118 
inertia in, 125 
rupture of uterus in, 125 
indications, 117 
manual method, 130 

after-coming head, 149 

head, 130 

lower extremities and 

breech, 136 
presenting arm, 135 
shoulders, 132 

cleidotomy for, 134 
trunk and upper extremi- 
ties, 142 
effect of anesthesia on, 35 
facial paralysis in, from forceps, 202 
fractures of cranial bones in, from for- 
ceps, 202 
injuries to, from forceps, 202 

in version, 232 
mortality and morbidity, after sym- 
physiotomy, 266 
mortality of, after pubiotomy, 276, 277 
premature, breech extraction with, 161 
results of pubiotomy for, 269, 276, 277 

of symphyseotomy for, 266 
retention of, after external version, 214 
wounds of scalp in, from forceps, 202 
Fibroid tumor of uterus, 56 

as cause of inversion, 360 
myomectomy for, 58 
Fistula, uterine, method of making, in 

suprasymphyseal section, 334, 336 
Flat pelvis, 125, 317, 326 
Floating head, 117 

kidney in pregnancy, 24 
Forceps, 163 

abrasions of face from, 202 
application of, after Cesarean section, 
194 
after pubiotomy, 194 
after suprasymphyseal extraperi- 
toneal section, 194 
after symphysiotomy, 194 
dangerous, 174 
high, 194 



470 



INDEX 



Forceps, application of, in contracted 
pelvis, 207 

in face presentation, 172, 173, 174, 
175 

low, 194 

middle, 194 

mortality from, 203 

repeated, 174 

to presenting part, 171 

with occiput posterior, 176, 177 
as an instrument, 163 
axis-traction, 165 

application of, 165 

Poulet's tapes with, 167 

Tarnier's, 167 
bad, 164 

cephalic curve of, 165 
complications caused by, 198 
conditions making use justifiable, 179 
contraindications for use, 181 
dangerous application, 174 
delivery, 163 

abrasions of face in, 202 

after Cesarean section, 194 

after pubiotomy, 194 

after suprasymphyseal extraperi- 
toneal section, 194 

after symphysiotomy, 194 

anesthesia in, 183 

application of forceps to presenting 
part, 171 

axis-traction, 165 

with Poulet's tapes, 167 
with Tarnier's forceps, 167 

complications, 198 

conditions making justifiable, 179 

contraindications, 181 

dangerous application of forceps, 174 

episiotomy in, 187 

facial paralysis in, 202 

fractures of cranial bones in, 202 

frequency, 203 

function of forceps, 178 

gauze compress of hot bichlorid solu- 
tion in, 186 

high, 194 

in contracted pelvis, 207 

in face presentation, 172, 173, 174, 
175 

indications, 178 

injuries caused by forceps, 198 



Forceps delivery, injury to coccyx in, 202 
to fetus in, 202 
to umbilical cord in, 202 
introduction of forceps, left blade, 
184 
locking blades, 185 
right blade, 185 
laceration of pelvic floor in, 201 

of urethra in, 201 
low, 194 

Mercurio's position in, 193 
middle, 194 
mortality from, 203 
of after-coming head, 153 
opening of vaginal cul-de-sac from, 

201 
position of patient, 182 

on side in, 190 
preparation of forceps, 182 

of patient, 182 
repeated apphcation of forceps, 174 
results, 203 
rotation with forceps in, 177 

deficient, 195 
separation of symphysis pubis in, 201 
technic, 182 
traction in, 186 
variations in, 189 
Walcher's position in, 193 
with occiput posterior, 176, 177 
wounds of scalp in, 202 
essential portions, 164 
facial paralysis from, 202 
fractures of cranial bones from, 202 
frequency of use, 203 
function of, 178 
good, 164 

indications for use, 178 
injuries from, 198 
injury to coccyx from, 202 
to fetus from, 202 
to umbilical cord from, 202 
laceration of pelvic floor from, 201 

of urethra from, 201 
lock of, 164 

mortality from use of, 203 
Naegele, 164 

opening of vaginal cul-de-sac from, 201 
pelvic curve of, 165 
repeated application, 174 
results of use, 203 



]Xi)i:x 



471 



Forceps, rotation with. 177 
deticient, 195 
separation of symphysis pubis from. 

201 
Simpson. 163 

tape attachment and traction bar, 

16S 
without traction bar, 167 
slipping from unengaged head, ISO. ISl 
solid-bladed, 164 
sterihzation of. 1S2 
Tarnier's. 163. 166 
wounds of scalp from. 202 
Formalin solution, 41 
Fracture, greenstick, in newborn. 446 
in newborn, siu-gical treatment. 444 
of clavicle, double, in newborn. 445 

in newborn. 444. 445 
of cranial bones from forceps. 202 
of cranium in version. 233 
of femur in newborn. 44S 
of humerus in newborn. 447 

in version, 232 
of thigh in version. 232 
of upper extremities in newborn, 444 
Frank's method of extraperitoneal sec- 
tion, 343 
Fungous growths of umbilicus in new- 
born. 459, 460 

Gall-bladder, infection of. in preg- 
nancy. 96 
Gauze, induction of labor by means of. 77 
Genital tract, asepsis of, 24 
bacteria in, 24 

enlargement, vaginal extraction pre- 
ceded by, 257 
in pregnancy, anatomy. 17 
lacerations of. immediate repair, 401 
accidents and complications 
after, 412 
intermediate repair, 413 
late repair. 414 
repair, after-treatment. 423 
hemorrhage after, 424 
infection after, 424 
patient's convalescence after, 

424 
technic. 422 
lower, condition of. as indicating 
vaginal delivery, 126 



Genital tract, n^turn to normal condition 

after labor, 22 
Gloves, rubber, sterihzation of, 41 
Cdycerin, sterile, induction of labor by 

means of, 77 
Greenstick fracture in newborn, 446 

H.\XDS, sterihzation of, 42 
Hare-lip in newborn, treatment, 457 
Harris' method for rapid dilation of cer- 
vix. 90 
Head, after-coming. deUvery of. by for- 
ceps, 153 
manual method, 149 
fetal, diameters of. 77 

manual extraction through vagina, 
130 
floating, 117 

injuries to, in version, 233 
Heart-faUure during anesthesia, treat- 
ment, 37 
Hebosteotomy. 267. See also Pahiotomy. 
Hematoma of cranium in newborn. 454. 
456 
treatment, 456 
of sternocleidomastoid mtiscle in new- 
bom, 454, 456 
treatment, 456 
of vagina after labor, 3SS 
Hemorrhage after celiohysierotomy. 313 
after labor, control, 376 
aclrenahn, 379 

apphcation of clamps to lacera- 
tions in cer^-ix, 379 
comphcated by toxemia. 379 
compression of abdominal aorta, 

380 
electricity, 3S1 

packing uterus with gauze. 376 
Sig\^-art's method, 3S0 
from lacerations in anterior seg- 
ment of pelvic floor, 389 
in posterior segment of pelvic 
floor, 387 
from rupture of uterus, 381 
from torn cervix, 385 
late, 384 
secondary, 382 

duty of nurse, 382, 383 
after repair of lacerations of genital 
tract, 424 



472 



INDEX 



Hemorrhage, control of, after labor, 376. 
See also Hemorrhage after labor. 
in labor, 371 
from hemorrhoidal veins in labor, 389 
in celiohysterectomy, control, 316 
in celiohysterotomy, control of, 305 
in labor, conditions preventing and 
controlling, 27 
control, 371 
in Porro operation, control, 325 
in pubiotomy, 271, 272 
into retina in newborn, 458 
late, after labor, 384 
of scalp in newborn, surgical treatment, 

453 
postpartum, control of, 376. See also 

Hemorrhage after labor. 
umbilical, in newborn, 442 
Hemorrhoidal veins, hemorrhage from, 

in labor, 389 
Hemorrhoids in pregnancy, 66 
Hernia of uterus, 55 

umbilical, in newborn, 443 
High application of forceps, 194 
Hook, Braun's, 253 
Hospitals, obstetric operations in, 39 
Houses, private, appliances for opera- 
tions in, 47 
obstetric operations in, 45 
operating tables in, 46 
selection of bed in, 46 
sterilization in, 47 
surgical dressings in, 48 
water supply in, 47 
Humerus, fractures of, in newborn, 447 

in version, 232 
Hydrosalpinx, 62 
Hysterectomy in pregnancy, 330 
in puerperal septic infection, 427 
in rupture of uterus, 329 

Immobilization of pelvis after pubiot- 
omy, 271 
after symphj'-seotomy, 265 
at time of symphyseotomy, 265 

Incision into pelvic floor and perineum, 
299 
of cervix, 287 

Incubator, 87 

Indentation of skull in newborn, 444 

Induction of labor, 69 



Induction of labor as a preliminarj' to 
other operations, 86 
by means of bougies, 76 

dilating bags with, 78, 81 
technic, 79 
of gauze, 77 
of sterile glycerin, 77 
care of child in, 86 
choice, 86 

for fetal deformit}^, 87 
indications, 69, 84 
methods, 76 
results, 83 

rupture of membranes in, 82 
technic, 79 
termination, 82 
test of labor, 76 
time for, 71 

Aliiller's method, 72, Fig. 50 
value, 84 
Inertia uteri in determining engagement 

in vaginal dehvery, 125 
Infants, preparation for care, in hospit- 
als, 44 
Infection after repair of lacerations of 
genital tract, 424 
in newborn, surgical treatment, 459 
of umbilicus in newborn, 459, 460 
septic, after celiohysterotomy, 314 
puerperal, 424. See also Puerperal 
septic infection. 
Inlet, pelvic, anteroposterior diameter, 
internal measurement, 72, 73 
diameters of, 74 
Instruments, 41 

for craniotomy, 241 
sterihzation of, in hospitals, 40 
Intestine, dilation of, after cehohyster- 
otomy, 313 
escape of, in celiohj^sterotomy, 310 
Inversion of uterus, 359 

caused by fibroids comphcating preg- 
nancy, 360 
caused by tumors complicating 

pregnancy, 360 
causes, immediate, 359 
conditions predisposing to, 359 
prophylaxis, 361 
results, 361 
signs, 360 
symptoms, 360 



IXDKX 



473 



Inversion of uterus, treatment, 361 
lodin, solution of tincture of, for irrigat- 
ing uterus, 41 

Jorg's method of extraperitoneal section, 

342 
Justominor pelvis. 126 I 

Kidney, floating, in pregnancy, 24 

operations on, in pregnancy, 97 

prolapse of, in pregnancy, 24 

siu-gical, treatment of. 434 
King's position in spontaneous version, 

234, 235 
Knee-chest position, 259, 260 I 

Kyphotic pelvis. 325 

Labor, bladder during and after, 23 
control of hemorrhage after, 376 
adrenalin, 379 

apphcation of clamps to lacera- 
tions in cervix, 379 
complicated by toxemia, 379 
compression of abdominal aorta, 

380 j 

electricity, 381 

packing uterus with gauze, 376 
Sigwart's method, 380 
control of hemorrhage in, 371 I 

hematoma of vagina after, 388 
hemorrhage after, control, 376. See 
also Labor, control of hemorrhage 
after. 
from lacerations in anterior seg- 
ment of pelvic floor, 389 
in posterior segment of pelvic 
floor, 387 
from rupture of uterus, 381 
from torn cervix, 385 
late, 384 
secondar}', 382 

duty of nurse, 382, 383 
from hemorrhoidal veins in, 389 
hemorrhage in, conditions preventing 
and controlling, 27 
control, 371 
induction of, 69 

as a preliminary- to other operations, 

86 
by means of bougies, 76 j 

dilating bags with, 78, 81 | 



Labor, induction of. by means of bougies, 
technie, 79 
of gauze, 77 
of sterile glycerin, 77 
care of child in, 86 
choice, 86 

for fetal deformity, 87 
indications, 69, 84 
methods, 76 
results, 83 

rupture of membranes in, 82 
technie, 79 
termination, 82 
test of labor, 76 
time for, 71 

Miiller's method, 72, Fig. 50 
value, 84 
knee-chest position in. 259. 260 
lateral position in, 259 
pelvic floor during, 21 
perineum during, 21 
position of uterus after, 22 

during, 19 
rectum during and after, 23 
retiu-n of birth-canal to normal condi- 
tion after, 22 
of uterus to normal position after, 22 
secondary hemorrhage after, 382 

duty of nurse, 382, 383 
sitting position in, 260 
squatting position in. 260 
surgery of, 117 

test of, in induction of labor, 76 
thrombosis of vagina after, 388 
twin, removal of placenta after, 369 
vagina during, 21 
Walcher's position in, 258, 259 
Laceration during dilation of cervix, 91, 
92 
in anterior segment of pelvic floor, 

postpartum hemorrhage from, 389 
in posterior segment of pelvic floor, 

postpartum hemorrhage from, 387 
of anterior segment of pelvic floor, 
immediate repair, 410 
secondary repair, 417 
of cervix, immediate repair, 402 

technie, 403 
of genital tract, immediate repair. 401 
accidents and complications 
after, 412 



474 



IXDEX 



Laceration of genital tract, intermediate 
repair, 413 
late repair, 414 
repair, after treatment. 423 
hemorrhage after, 42-± 
infection after, 424 
patient's convalescence after, 

424 
technic, 422 
of pelvic floor, 65 

complete, immediate repair, 40S 
repair of, after-treatment, 423 
secondary- repair. 417 
Emmet's operation for repair, 416 
from forceps, 201 
immediate repaii', complications 

after, 411 
late repair, 416 
of perineum, 65 

complete, immediate repair, 40S 
repair of, after-treatment, 423 
secondary repair, 417 
immediate repau-. 407 

complications after, 411 
unusual,- closiue of, 411 
of posterior segment of pehic floor and 

perineum, immediate repau, 404 
of urethra from forceps, 201 
of uterus, repair, 56 
Laparo-ebv-trotomy, 342 
Lateral position, 259 
Leg, milk, surgical treatment, 429 
Ligature material. 44 
Locomotion, disturbances of, after pubi- 

otomy, 2S3 
Low application of forceps, 194 
Lower extremity, thrombophlebitis of. 

surgical treatment, 429 
Lumbar injection, anesthesia by, 33 
with eucaiu-adrenalin, 35 
with scopolamin morphin, 34, 35 
vdxh stovain. 34 
Lysol, 41 

Mastitis in newborn, 439 
puerperal, 436 
treatment of, 437 
Measurement, internal, of anteroposter- 
ior diameter of pelvic inlet, 72. 73 
of anteroposterior diameter of pelvic 
outlet, 70 



Measurement of transverse diameter of 

pelvic outlet, 71 
Membranes, rupture of, in induced labor, 
82 
in placenta prgevia, 395 
Mercurio's position, 257 

in forceps dehvery. 193 
Mercury, bichlorid of, 41 
Middle application of forceps. 194 
'Mi]k leg, sm'gical treatment, 429 
]\Iomburg's bandage in placental separa- 
tion, 399 
^Mailer's method of estimating time for 

induction of labor, 72, Fig. 50 
Multiple abscess complicating puerperal 

state, 434 
]^-Iuscle, sphincter, immediate repair, 407 
sternocleidomastoid, in newborn, hema- 
toma of, 454, 456 
surgical treatment, 456 
■Muscles, recti, diastasis of, after labor, 

correction, 422 
^lyomectomy for fibroid tumor of uterus, 
58 

Xaegele forceps, 164 
Newborn, abscess of breast in. 439 
asphyxia in, 441 
brachial palsy in. sm-gical treatment, 

449 
cephalhematoma in, 454 

surgical treatment, 456 
circumcision in, 460 

complications. 462 
cleft palate in, treatment, 457 
congenital lack of development. 458 
dislocation of eye in. 45S 
fractiue of cla^-icle in. 444, 445 
double, 445 

of femiu in, 44S 

of hiunerus in. 447 
fractures ia, sm-gical treatment, 444 

of upper extremities in, 444 
fungous growths of imibihcus in, 459, 

460 
greenstick fractm'e in. 446 
hare-hp in, treatment, 457 
hematoma of cranium in. 454. 456 

treatment, 456 
hemorrhage into retina in. 458 

of scalp in, siugical treatment, 453 



[XDEX 



Newborn, indent at ion of skull in, 444 
infection in, surgicul treatment, 459 

of umbilicus in, 459, 460 
injuries to ear in, 457 
to eye in, 458 

to scalp in, surp;ical treatment, 453 
lesions of face in, 45() 
mastitis in, 489 
surgery of, 441 
torticollis in, 456 
treatment, 456 
umbilical hemorrhage in, 442 

hernia in, 443 
wounds of ear in, 457 
of eye in, 458 
of face in, 457 
Newell's dilator for dilation of uterus, 90 
Nipples, asepsis of, 41 
Nitrate of silver in ophthalmia neonato- 
rum, 41 
Nitrous oxid anesthesia, 30 
Nurse, duty of, in secondary postpartum 

hemorrhage, 382, 383 
Nursing, 50 

Open symphyseotomy, 264 
Operating tables in hospitals, 39 

in private houses, 46 
Operating-room in hospitals, 39 
cleaning and fumigation, 45 
Operator, asepsis of, 42 
Ophthalmia neonatorum, argyrol in, 41 

nitrate of silver in, 41 
Outlet, pelvic, anteroposterior diameter, 
measurement, 70 
deformity in, in vaginal delivery, 127 
diameters of, 70 

transverse diameter, measurement, 
71 
Ovarian pregnancy, operation in, 109 
Ovaries, cysts of, 62, 63 
operations on, 62 
tumors of, 64 
Ovariotomy, 64 

Palate, cleft, in newborn, treatment, 

457 
Paralysis, brachial, in newborn, surgical 
treatment, 449 

facial, from forceps, 202 
Parietal presentation, anterior, 121 



Parietal presentation, j)ost(Tior, 121 
Patients, preparation of, in hospitals, 43 
Pelvic abscess, Pryor's treatment, 431 
surgical treatment, 430 
excavation, diameters of, 78 
floor, anterior segment, lacerations of, 
lunnorrhage after labor 
from, 389 
immediate repair, 410 
secondary repair, 418 
during labor, 21 
incision into, 299 
lacerations of, 65 

complete, immediate repair, 408 
repair of, after-treatment, 423 
secondary repair, 417 
Emmet's operation, 416 
from forceps, 201 
immediate repair, complications 

after, 411 
late repair, 416 
operations on, 65 

posterior segment, lacerations of, 
hemorrhage after labor 
from, 387 
immediate repair, 404 
inlet, anteroposterior diameter, inter- 
nal measurement, 72, 73 
diameters of, 74 
outlet, anteroposterior diameter, meas- 
urement, 70 
deformity of , in vaginal delivery, 127 
diameters of, 70 

transverse diameter, measurement, 
71 
thrombophlebitis, surgical treatment, 
428 
Trendelenburg's operation for, 428 
viscera, prolapse of, after labor, cor- 
rection, 420 
Pelvis, condition of, after pubiotomy, 281 
contracted, application of forceps in, 
207 
irregularly, 127 
version in, results, 229 
enlargement of, permanent, after pub- 
iotomy, 276 
Schickele's operation for, 282 
flat, 125, 317, 326 

immobilization of, after pubiotomy, 
271 



476 



IXDEX 



Pelvis, immobilization of. after sym- 
physeotomj^, 265 
at time of SATaphyseotomy, 265 
justominor, 126 
k>'photic, 325 

mobility of, in pregnancy, 257 
rachitic, 317, 319 
section of, 261 
Perinemn dming labor, 21 
incision into, 299 
lacerations of, 65 

complete, immediate repair. 40S 
repair of, after-treatment, 423 
secondary- repair, 417 
immediate repair. 407 

complications after, 411 
imusual closure, 411 
operations on, 65 

section of, vaginal extraction preceded 
by. 2S7 
Peritonitis, puerperal, 431 

sm-gical treatment, 432 
Pfannenstiel's incision in suprasymphy- 
seal section, 334 
treatment of placenta praevia. 391 
Piles in pregnancy, 66 
Placenta, adherent, removal of, 366, 367 
detachment of, in version, 232 
normally implanted, premature de- 
tachment, 397. See also Placenta, 
separation of. 
praevia, 390 

Braxton-Hicks' treatment, 391 
central, 373, 390 
cer^-ical section in, 394 
Cesarean section ha, 391. 393. 396 
combined version for, 215 
complete. 373, 390 
dilatmg bag m, 391, 393 
incomplete, 390 

som-ce of bleeding in. 374 
partial. 390 

Pfannenstiel's treatment. 391 
rupture of membranes in, 395 
tampon in, 391 
treatment, 390 

conser^'ative results of, 392 
vaginal Cesarean section for, 294 
tampon in, 374 
removal of, 365 

manual, after uterine rupture, 368 



Placenta, removal of. manual, bypiiUing 
upon umbilical cord, 370 
in tvrin labor, 369 
indications for, 365 
methods for. 366 
precautions in, 367 
separation of, 397 

]vlomburg's bandage in, 399 
mortahty, 398 
rotunda treatment. 399 
s>Tnptoms, 398 
tampon m, 398, 399 
treatment. 398 
Plexus, brachial, in newborn, injiuies to, 

449 
Pneumonia after ether anesthesia. 36 
Podahc version, 210, 220. 224 
Polk's operation for prolapse of uterus, 

420 
Pohps of uterus, removal. 59 
Porro's operation. 320 

blood-pressiu-e during, chart of. 324 
comphcations. 325 
hemorrhage in, control, 325 
indications, 320 
recover}' from, 323 
technic, 321 
Position in forceps delivery, 1S2 

King's, in spontaneous version. 234, 

235 
knee-chest, 259. 260 
lateral, 259 
Mercurio's. 257 

in forceps dehvery, 193 
of cecum in pregnancy, 93 
of vermiform appendix in pregnancy, 

93 
on side in forceps delivery. 190 
sitting, 260 
squatting. 260 
Walcher's. 258, 259 
in forceps dehvers', 193 
Postpartum hemorrhage, control. 376 
adrenalin, 379 

apphcation of clamps to lacera- 
tions in cer\Tx, 379 
comphcated by toxemia, 379 
compression of abdominal aorta, 

3S0 
electricity. 381 
packing uterus with gauze, 376 



INDEX 



477 



Postpartum hemorrhage, control, 8ig- 
wart's method, 380 
from lacerations in anterior segment 
of pelvic floor, 389 
in posterior segment of pelvic floor, 
387 
from rupture of uterus, 381 
from torn cervix, 385 
late, 384 
secondary, 382 

duty of nurse, 382, 383 
Postural enlargement, 257 
Poulet's tapes with axis-traction forceps, 

167 
Pregnancy, abdomen during, 23 
abdominal operation in, 99, 108 
anesthesia during, 29. See also Anes- 
thesia. 
anteflexion of uterus in, 18, 51 
appendicitis in, operation for, 93 
asepsis of birth-canal in, 24 
bacteria in birth-canal during, 24 
birth-canal in, anatomy, 17 
asepsis of, 24 
bacteria in, 24 
carcinoma of uterus in, 59 
cholecystotomy in, 96 
cornual, operation in, 109 
cysts of ovaries in, 62, 63 
dislocation of spleen in, 24 
displacements of uterus in, 51 

cause, 51 
eclampsia in, Edebohls' operation for, 

98 
ectopic, irritation of bladder in, 110 
of rectum in, 110 
operation for, 100-112 
rupture of, operation in, 106, 107 
suppurating, 110, 111 
exercise in, value of, 260 
extirpation of uterus in, 330 
extra-uterine, 100. See also Pregnancy, 

ectopic. 
fibroid tumor of uterus in, 56 

myomectomj' for, 58 
floating kidney in, 24 
hemorrhoids in, 66 
hernia of uterus in, 55 
hydrosalpinx in, 62 
hysterectomy in, 330 
infection of gall-bladder in, 96 



Pregnancy, knee-chest postun^ in, 259, 

260 
laceration of pelvic floor in, 65 

of perineum in, 65 

of uterus in, repair, 56 
lateral position in, 259 
Mercurio's posture in, 257 
mobility of pelvis in, 257 
operations on Fallopian tubes in, 62 

on kidneys in, 97 

on ovaries in, 62 

on pelvic floor in, 65 

on perineum in, 65 

on rectum in, 66 
ovarian, operation in, 109 

tumors in, 64 
ovariotom}' in, 64 
piles in, 66 

poh-ps of uterus in, removal, 59 
position of cecum in, 93 

of uterus during development, 17 

of vermiform appendix in, 93 
prolapse of kidnej' in, 24 

of uterus in, 55 
pyehtis in, 97 

retroflexion of uterus in, 17, 51 
retroversion of uterus in, 51 

retaining uterus in normal position 
after replacement, 54 
salpingitis in, 62 

chronic, 63 
sitting posture in, 260 
size of uterus in, 18 
squatting posture in, 260 
surgery of, 28, 51 
tubal, operation in, 109 
tumors complicating, inversion of 
uterus caused by, 360 

of ovary in, 64 

of uterus in, remoA'al, 56 
uterus in, size of, 17 
value of exercise in, 260 
vermiform appendix in, 24 
Walcher position in, 258, 259 
Premature detachment of normally im- 
planted placenta, 397. See also 

Placenta, separation of. 
fetus, breech extraction with, 161 
Preparation of patients in hospitals, 43 
Presentation, breech, engagement in, 122 

version in, 226 



478 



INDEX 



Presentation, brow, engagement in, 121, 

123 
face, application of forceps in, 172, 173, 
174, 175 

engagement in, 123 
parietal, anterior, 120 

posterior, 121 
shoulder, impacted, combined version 

for, 217 
Private houses, appliances for operation 
in, 47 

obstetric operations in, 45 

operating tables in, 46 

selection of bed in, 46 

sterilization in, 47 

surgical dressings in, 48 

water supply in, 47 
Prolapse of kidney in pregnancy, 24 
of pelvic viscera after labor, correction, 

420 
of urethra, repair, 418 
of uterus, 55 

Polk's operation for, 420 
Prophylactic version, 210 
Pryor's treatment of pelvic abscess, 431 
Pubiotomy, 267 
advantages of, 269 
Baumm's method, 273 
bony union after, failure of, 282 
Bumm's method, 271, 272 
complications of, 270 
condition of pelvis after, 281 
delivery after, 269 
disadvantages of, 269 
disturbances of locomotion after, 283 
Doderlein's method, 270 
double, 269 

enlargement of pelvis after, permanent, 
276 
Schickele's operation for, 282 
failure of bon}^ union after, 282 
forceps delivery after, 194 
hemorrhage in, 271, 272 
immobilization of pelvis after, 271 
indications for, 267 
injury to bladder in, 272 
mortality from, 272, 275, 277 
open method, 274 
pelvis after, 281 
permanent enlargement of pelvis after, 

276 



Pubiotomy, permanent enlargement of 
pelvis after, Schickele's operation 
for, 282 
place of, as an operation, 272 
repeated, 269 

results of, for child, 269, 276, 277 
subcutaneous, 268 
technic of, 267, 270 
thrombosis after, 277 
version after, 229 
Puerperal mastitis, 436 
treatment, 437 
peritonitis, 431 

surgical treatment, 432 
septic infection, complete extirpation 
of uterus for, 427 
emptying septic uterus, 425 
hysterectomy for, 427 
surgery of, 424 
Puerperium, multiple abscess complicat- 
ing, 434 
surgery of, 365 
Pyelitis in pregnancy, 97 

Rachitic pelvis, 317, 319 

Recti muscles, diastasis of, after labor, 

correction, 422 
Rectum during and after labor, 23 
fetal debris in. 111 

irritation of, in ectopic pregnancy, 110 
operations on, 66 
Relaxation of abdominal wall after labor, 

correction, 422 
Results of induced labor, 83 
Retina, hemorrhage into, in newborn, 458 
Retroflexion of uterus, 51 

in pregnancy, 17 
Retroversion of uterus, 51 
after labor, 419 

retaining uterus in normal position 
after replacement, 54 
Ritgen's method of extraperitoneal sec- 
tion, 342 
Room, confinement, 45 
operating-, in hospitals, 39 
cleaning and fumigation, 45 
Rotation with forceps, 177 

deficient, 195 
Rotunda method of treating placental 

separation, 399 
Rubber gloves, sterilization of, 41 



[Ni)i<:.\ 



479 



Rupture of niouihratu's in iiuhi('(>(l labor, 
82 

in phiconia i)rania, iiO") 
of ectopic prejinancy, operation in, 1(K), 
107 
suppuratinu;, 110, 111 
of uterus, 349 

danger of, in combined version, 220 
in version, 232 

emptying uterus and use of tampon 
in, 328 

etiology, 349 

hemorrhage after labor from, 381 

hysterectomy in, 329 

in determining engagement in vag- 
inal delivery, 125 

morbidity, 356 

mortality, 356 

natural history, 350 

prevention, 352 

removal of placenta after, 368 

signs, 350 

symptoms, 350, 351 

threatened, symptoms, 351 

treatment, 328, 353 
results, 330 

varieties, 349 



Salpingitis, 62 

chronic, 63 
Salt solution in celiohj^sterotomj', 304, 

307 
Scalp, hemorrhage of, in newborn, sur- 
gical treatment, 453 
injuries to, in newborn, surgical treat- 
ment, 453 
wounds of, from forceps, 202 
Schickele's operation for permanent en- 
largement of pelvis after pubiotomy, 
282 
Scissors, Smelley's, for craniotomy, 241 
Scopolamin-morphin anesthesia by lum- 
bar injection, 34, 35 
Section, abdominal, delivery by, 300 
methods, 300 
in pregnancy, 99 
in rupture of uterus, 329 
results, 327 
with sterilization, 314 
cervical, in placenta prajvia, 394 



\ Section, Cesarean, 301. S(>e also CcUo- 
In/slcroloniij. 
extraperit()n(>al, by inguinal incision, 
341 
Doderlein's iru^thorl, 343-349 
Frank's method, 343 
Jorg's method, 342 
Ritgen's method, 342 
Thomas' method, 342 
of cervix, vaginal extraction {preceded 

by, 287 
of lower uterine segment, vaginal ex- 
traction preceded by, 287 
of perineum, vaginal extraction pre- 
ceded by, 287 
suprasymphyseal, 333 
advantages of, 335 
disadvantages of, 335 
extraperitoneal, application of for- 
ceps after, 194 
in septic cases, 336 
Pfannenstiel's incision in, 334 
results of, 335 
Sellheim's method, 335 

of making uterine fistula in, 334, 
336 
technic of, 334 
version after, 229 
through lower uterine segment, ver- 
sion after, 229 
Segment, anterior, of pelvic floor, lacera- 
tions, immediate repair, 410 
secondary repair, 418 
posterior, of pelvic floor, lacerations, 

immediate repair, 404 
uterine, lower, section of, vaginal ex- 
traction preceded by, 287 
Sellheim's method of making uterine 
fistula in suprasymphyseal sec- 
tion, 334, 336 
of suprasymphyseal section, 335 
Separation of placenta, 397. See also 

Placenta, separation of. 
Septic infection after celiohj'sterotoniy, 
314 
puerperal, 424. See also Puerperal 
septic infection. 
Shoulder presentation, imf)actod, com- 
bined version for, 217 
Shoulders, fetal, manual extraction 
through vagina, 132 



480 



IXDEX 



Sigwart's method of controlling postpar- 
tum hemorrhage. 3S0 
Silver nitrate in ophthalmia neonatorum, 

41 
Simpson's forceps. 163 

tape attachment and traction bar, 
168 
without traction bar. 167 
Sitting position, 260 
Skull, indentation of, in newborn, 444 
Smelley's scissors for craniotomy, 241 
Sphincter muscle, immediate repair', 407 
Spinal anesthesia, 33 
Spleen, dislocation of. in pregnancy, 24 
Spontaneous version, 233 

Iving's position in, 234, 235 
Squatting position, 260 
Sterihzation, abdominal section with. 314 
apparatus for, in hospitals. 40 
in private houses, 47 
of bougies, 40 
of dilating bags, 40 
of forceps, 182 
of hands, 42 

of instruments in hospitals. 40 
of rubber gloves. 41 
Sternocleidomastoid muscle, hematoma 
of, in newborn. 454. 456 
treatment, 456 
Stitch-hole abscess after celiohysterot- 

omy, 314 
Stomach, dilation of. after celiohyster- 

otomy, 313 
Stovain anesthesia by lumbar mjection, 

34 
Subcutaneous pubiotomy, 268 

sjmiphyseotomy, 264 
SuprasjTnphyseal section, 333 
advantages, 335 
disadvantages, 335 
extraperitoneal, use of forceps after, 

194 
in septic cases, 336 
Pfannenstiers incision in, 334 
results, 335 
SelLheim's method, 335 

of making uterine fistula in, 334, 
336 
technic, 334 
version after, 229 
Surgical dressings in private houses, 48 



Surgical kidne^', treatment, 434 
Suture, immediate, of lacerations of an- 
terior segment of pelvic floor, 
410 
of genital tract. 401 
of peh'ic floor, comphcations after, 

411 
of perineimi. comphcations after, 
411 
intermediate, of lacerations of genital 

tract. 413 
late, of lacerations of genital tract, 414 
material, 44 

of complete lacerations of pelvic floor, 
immediate, 408 
of perineimi, immediate, 408 
of episiotomy wounds, 410 
of lacerations of cei-^dx, immediate, 402 
technic of, 403 
of genital tract, after-treatment, 423 
hemorrhage after, 424 
infection after, 424 
patient's convalescence after, 

424 
technic, 422 
of perineimi, immediate, 407 
of posterior segment of pelvic floor 
and perineum, 404 
of prolapse of urethra, 418 
of sphincter muscle, immediate, 407 
secondary, of complete lacerations of 
pelvic floor, 417 
of perineum, 417 
of lacerations of anterior segment of 
pelvic floor, 418 
SjTnphj'seotomy, 261 
accidents of, 265 
comphcations of, 265 
. fetal mortahty and morbicUty after, 266 
forceps dehver>' after, 194 
immobilization of pehis after, 265 

at time of, 265 
indications for, 262 
methods of, 263 
mortahty and morbidity, 266 

fetal, 266 
open, 264 
results of, 265 
for child. 266 
permanent. 266 
subcutaneous, 264 



INDEX 



481 



Symphyseotomy without extraction. 267 Timaors of uteni*. removal, 56 

S>-mphysis pubis, sq[>aratioii of, from for- ovarian, 64 

ceps, 201 Twin labor, removal of placenta in, 369 

Tables, operating, in hospitals, 39 Umbilical cord, injury to, from forceps, 

in private houses, 46 202 

Tampon in placenta pne\ia, 391 in version, 22S. '233 

in placental separation. 398, 399 pulling upon, for removal erf placenta^ 

intra-uterine. in postparttmi hemor- 370 

rhage, 376 hemorrhage in newborn, 442 

vaginal, in placenta praevia, 374 h^nia in newborn, 443 

Tapes, Poulet's. with axis-traction for- Umbilicus, fimgous growths of. in new- 

ceps. 167 bom, 459. 460 

Tamier's forceps. 163. 166. 167 infection of. in newborn. 459. 460 

Technic of obstetric siirger\-. 39 Ujqjer extremities, fractures of, in new- 

TCTminarion erf induced labcH', 82 bom, 444 

Tests of labor in inducrion of labor. 76 Urethra, lacerarion <rf. from forceps, 201 

Therapeuric abortion. 66 prolajxse of. repair. 41S 

anesthetic for. 67 Uterine fistula, metbod of making, in 

technic. 67 ^q^asymj^yseal section, 334, 336 

ThigJu fractine of, in vCTsion, 232 tampon to control postpartum hemcH'- 

Thomas^" method erf extraperitoneal sec- rhage, 376 

tion. 342 Uterus, anteflexion of, 51 

Thorn's method for converting a face into in pregnancy, 18 

a vertex presentation, 212 anteveision (rf, after labtH*, correction. 

Thrombophlebitis of lower extremity. 419 

surgical treatment. 429 carcinoma of, 59 

pelvic, surgical treatment. 42S closure of. ar:?r i-eliohysterotomy. 305. 

Trendelenbing's operation for. 42S 307 

Thrombosis afto" pubiot<Hny, 277 dilation of. rapi i :-,z : : : r ::': It >9 

(rf va^na after labcH", 388 Bo^'s diL\: : : : : - 

Tincture of iodin solution f(H" irrigiating dilators for, S9 

trterus, 41 dastic ba^ for, 90 

Torticollis in newborn. 456 ' Harris's method, 90 

treatment. 456 laceration dtmng. 91. 92 

Toxonia compUcating postpartum hesn- mtiltiple incisions for. 90 

orrhage, control. 379 Xewefl's dilator for. 90 

Tracheotomy for asphyxia in newborn. displacements of. 51 

441 aftei- labor, correction, technic of. 422 

Transverse diameter <rf pdvic outlet, with <m" without lacerations. 

measurement. 71 419 

Trendelenburgs operation for pelvic cause, 51 

thrombophlebitis. 42s emptying of. after viabiUty and befwe 

Trephine. 242. 24:3 fuU term. 69 

Trimk and upper extremities of fetus. brfore viability. 66 

manual method of vaginal dehvery, 142 fibroid tinnors of, 56 

Tubal pregnancy, operation in. 109 as cause of inversion. 360 

Tiunors compUcating pregnancy, inver- myomect<Hny ior, 5S 

sion of uterus caused by. 360 hernia of. 55 

fibroid, of uterus. 56 incision of, in cdiohystcrotomy. 302. 

myomectomy for, 5S 305 
31 



482 



INDEX 



Uterus, inversion of, 359 

caused by fibroids complicating 
pregnancy, 360 
by tumors complicating preg- 
nancy, 360 

causes, immediate, 359 

conditions predisposing to, 359 

prophylaxis, 361 

results, 361 

signs, 360 

symptoms, 360 

treatment, 361 
lacerations of, repair, 56 
packing of, with gauze, to control hem- 
orrhage after labor, 376 
polyps of, removal, 59 
position of, after labor, 22 

during development, 17 

during labor, 19 
pregnant, total extirpation, 330 
prolapse of, 55 

Polk's operation for, 420 
rapid and forcible dilation, 89 
relaxed, in celiohysterotomy, 310 
retroflexion of, 51 

in pregnancy, 17 
retroversion of, 51 

after labor, 419 

retaining uterus in normal position 
after replacement, 54 
return to normal position after labor, 

22 
rupture of, 349 

abdominal section in, 329 

danger, in combined version, 220 
in version, 232 

emptying uterus and use of tampon 
in, 328 

etiology, 349 

hemorrhage after labor from, 381 

hysterectomy in, 329 

in determining engagement in vagi- 
nal delivery, 125 

morbidity, 356 

mortality, 356 

natural history, 350 

prevention, 352 

removal of placenta after, 368 

signs, 350 

symptoms, 350, 351 

threatened, symptoms, 351 



Uterus, rupture of, treatment, 328, 353 
results, 330 
varieties, 349 
segment of, lower, section of, vaginal 

extraction preceded by, 287 
size of, in pregnancy, 18 
tumors of, removal, 56 

Vagina during labor, 21 

hematoma of, after labor, 388 
thrombosis of, after labor, 388 
Vaginal Cesarean section, 289 
application of, 295 
complications after, 292 
for placenta prsevia, 294, 393 
indications, 291, 295 
technic, 289 
version after, 229 
cul-de-sac, opening of, from forceps,. 

201 
delivery of fetus, 117 

after-coming head, by forceps, 153 
condition of lower birth-canal as 

indicating, 126 
deformity of pelvic outlet in, 127 
determining engagement, 118 
inertia in, 125 
rupture of uterus in, 125 
incision into pelvic floor and per- 
ineum in, 299 
of cervix in, 287 
indications, 117 
manual method, 130 

after-coming head, 149 

head, 130 

lower extremities and breech,. 

136 
presenting arm, 135 
shoulders, 132 

cleidotomy for, 134 
trunk and upper extremities, 
142 
preceded by enlargement of birth- 
canal, 257 
by section of cervix, 287 

of lower uterine segment, 287 
of perineum, 287 
vaginal Cesarean section in, 289 
tampon in placenta prsevia, 374 
Veins, hemorrhoidal, hemorrhage from, 
in labor, 389 



INDEX 



483 



\'ormiforin appendix in ])rop;nanry, 24 I 

position of, in piTj2;nan('y, 93 
Version, 210 

after pubiotoniy, 229 

after section throuf2;h lower uterine 

segment, 229 
after suprasyniphyseal section, 229 
after vaginal Cesarean section, 229 
anesthesia in, 213, 222 
bipolar, 221, 222, 223, 225 
Braxton-Hicks' method, 215 
cephalic, 210 
combined, 210, 215 

danger of uterine rupture in, 220 

for impacted shoulder presentation, 
217 

for placenta praevia, 215 

indications for, 215 

preparation for, 215 
danger of uterine rupture in, 232 
detachment of placenta in, 232 
dilation of cervix in, 236 
external, 210, 214 

advantages of, 215 

retention of child after, 214 
fracture of cranium in, 233 

of humerus in, 232 

of thigh in, 232 
in breech presentation, 226 
in contracted pelvis, results, 229 
indications for, 210, 220 
infection in, 233 



\'(Tsion, injuri(^s to face in, 233 

(() fetus in, 232 

to head in, 233 

to imibilical cord in, 22<S, 233 
internal, 210, 220 
mortality from, 230 
po(lalic,'210, 220, 224 
position of patic^nt in, 221 
preparation of patient for, 213 
prognosis of, 236 
prophylactic, 210 
results of, 229 
spontaneous, 233 

King's position in, 234, 235 
successful, essentials for, 213 
technic of, 221 
Thorn's method, 212 
varieties of, with reference to fetus, 210 
to mother, 210 
Viscera, pelvic, prolapse of, after labor, 
correction, 420 



Walcher's position, 258, 259 

in forceps delivery, 193 
Water supply in private houses, 47 
Wounds, episiotomy, closure of, 410 
of ear in newborn, 457 
of eye in newborn, 458 
of face in newborn, 456 
of scalp from forceps, 202 

in newborn, surgical treatment, 453 



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taken with the illustrations, in order to have them as practical and as helpful as 
possible, and at the same time highly artistic. A large num.ber represent the 
best work of Mr. H. F. Aitken. 



PERSONAL AND PRESS OPINIONS 



Frank Allport. M. D. 

Professor of Otology, Northwestern University, Chicago. 

" I regard it as one of the best books in the English language on this subject. The 
pictures are especially good, particularly as they are practically all original and not the old 
reproduced pictures so frequently seen." 

C. C. Stephenson, M. D. 

Professor of Ophthalmology and Otology, College of Physicians and Surgeons, Little Rock 
Arkansas, 

" To my mind there is no work on modem otology that can for a moment compare with 
' Barnhill and Wales.' " 

Journal American Medical Association 

" Its teaching is sound throughout and up to date. The strongest chapters are those on 
suppuration of the middle ear and the mastoid cells, and the intracranial complications of ear 
disease." 



DISEASES OF THE EYE. 



DeSchweinitz's 
Diseases of the Eye 



The New (6th) Edition 



Diseases of the Eye ; A Handbook of Ophthalmic Practice. 
By G. E. deSchweinitz, M.D., Professor of Ophthalmology in the Uni- 
versit)' of Pennsylvania, Philadelpliia, etc. Handsome octavo of 945 
pages, 354 text-illustrations, and 7 chromo-hthographic plates. Cloth, 
^5.00 net; Sheep or Half Morocco, S6.50 net 

WITH S54 TEXT-ILLUSTRATIONS AND 7 COLORED PLATES 
THE STANDARD AUTHORITY 

Dr. deSchweinitz' s book has long been recognized as a siar.dard auihcnn.- 
upon eye diseases, the reputation of its author for accuracy 01 statement piacing it 
far in the front of works on this subject. For this edition Dr. deSchweinitz has 
subjected his book to a most thorough revision. Fifteen new subjects have been 
added, ten of those in the former edition have been rewritten, and throughout the 
book reference has been made to vaccine and serum therapy, to the relation of 
tuberculosis to ocular disease, and to the value of tuberculin as a diagnostic and 
therapeutic agent. 

The text is hilly illustrated with black and white cuts and colored plates, and 
in ever\- way the book maintains its reputation as an authorit%- upon the eye. 



PERSONAL AND PRESS OPINIONS 



Samuel Theobald. M.D., 

Clinical Prcfessor of Ophthalmology, Johns Hopkins Universiiy, Baltiwwre. 
" It is a work that I ha^e held in high esteem, and is one of the two or three books upon 
the eve which I have been in the habit of recommending to my students in the Johns Hopkins 

Medical SchooL" 

Uoivenity of Pennsylvania Medical Bulletin 

• Upon reading through the contents of this book we are impressed by the remarkable 
fulness with which it reflects the notable contributions recently made to ophthalmic literature. 
No important subject within its province has been neglected." 

Johns Hopkins Hospital Bulletin 

No single chapter can be selected as the b^L They are all the product of a finished 
authorship and the work of an exceptional ophthalmologist. The work is certainly one of the 
best on ophtbalmolc^y extant, and probably the best by an American author." 



SAUNDERS' BOOKS OX 



Brtihl, Politzer, and Smith's 
Otology 



Atlas and Epitome of Otology. By Gustav Bruhl, I\I. D., of 
Berlin, with the collaboration of Professor Dr. A. Politzer, of 
Vienna. Edited, with additions, by S. ]\IacCuex Smith. ^I.D.. Pro- 
fessor of Otology' in the Jefferson IMedical College, Pliiladelphia. 
With 244 colored figures on 39 lithographic plates, 99 text illustra- 
tions, and 292 pages of text. Cloth, S3.00 net. I?i Smmders' Hand- 
Atlas Series. 

INCLUDING ANATOMY AND PHYSIOLOGY 

The work is botii didactic and clinical in its teaching. A special feature is 
the ver\- complete exposition of the minute anatomy of the ear, a working knowl- 
edge of which is so essential to an intelligent conception of the science of otolog^^ 
The association of Professor Politzer and the use of so many valuable specimens 
from his notably rich collection especially enhance the value of the treatise. The 
work contains ever\-thing of importance in the elementar\- study of otology. 

Clarence J. Blake, M. D., 

Professor of Otology in Harvard University Medical School, Boston. 

" The most complete work of its kind as vet published, and one comm.ending itself to both 
the student and the teacher in the character and scope of its illustrations." 

Haab and deSchweinitz's 
Operative Ophthalmology 

Atlas and Epitome of Operative Ophthalmology. By Dr. O. 

Haab, of Zurich. Edited, with additions, by G. E. de Schweinitz, 
M. D., Professor of Ophthalmology^ in the University- of Pennsylvania, 
With 30 colored lithographic plates, 1 54 text-cuts, and 375 pages of 
text. In Saunders' Hand- Atlas Series. Cloth, $3.50 net. 



Dr. Haab's Atlas of Operative Ophthalmology -w-ill be found as beautiful and 
as practical as his two former atlases. The work represents the author's thirty 
years' experience in eye work. The various operative interventions are described 
v^-ith all the precision and clearness that such an experience brings. Recognizing 
the fact that mere verbal descriptions are frequently insufficient to give a clear 
idea of operative procedures, Dr. Haab has taken particular care to illustrate 
plainly the different parts of the operations. 

Johns Hopkins Hospital Bulletin 

■■ The descriptions of the various operations are so clear and full that the voJume can well 
hold place with more pretentious text-books." 



DISEASES OF THE EYE. 



Haab and DeSchweinitz's 
External Diseases qf the Eye 



Atlas and Epitome of External Diseases of the Eye. By Dr. O. 

Haab, of Zurich. Edited, with additions, by G. E. deSchweinitz, 
M. D., Professor of Ophthalmology, University of Pennsylvania. With 
1 01 colored illustrations on 46 lithographic plates and 244 pages of 
text. Cloth, $3.00 net. I?i Saunders' Hatid- Atlas Series. 

THE NEW (3d) EDITION 

Conditions attending diseases of the external eye, which are often so complicated, 
have probably never been more clearly and comprehensively expounded than in 
the forelying work, in which the pictorial most happily supplements the verbal 
description. The price of the book is remarkably low. 

The Medical Record, New York 

" The work is excellently suited to the student of ophthalmology and to the practising 
physician. It cannot fail to attain a well-desers-ed popularity." 

Haab and DeSchweinitzV 
Ophthalmoscopy 



Atlas and Epitome of Ophthalmoscopy and Ophthalmoscopic 
Diagnosis. By Dr. O. Haab, of Zurich. Edited, with additions, by 
G. E. deSchweinitz, ]\I. D., Professor of Ophthalmology, University 
of Pennsylvania. With 152 colored lithographic illustrations and 92 
pages of text. Cloth, S3. 00 net. hi Saunders' Hand-Atlas Series. 

THE NEW (2d) EDITION 

The great value of Prof. Haab's Atlas of Ophthalmoscopy and Ophthalmo- 
scopic Diagnosis has been fully established and entirely justified an Englifh 
translation. Not only is the student made acquainted with carefully prepared 
ophthalmoscopic drawings done into well-executed hthographs of the most im- 
portant fundus changes, but, in many instances, plates of the microscopic lesions 
are added. The whole furnishes a manual of the greatest possible service. 

The Lancet, London 

"We recommend it as a work that should be in the ophthalmic wards or in the library of 
every hospital into which ophthalmic cases are received." 



SAUNDERS' BOOKS ON 



Cradle's 
Nose» Pharynx, and Ear 

Diseases of the Nose, Pharynx, and Ear. By Henry Gradle, 
M. D., Professor of Ophthalmology and Otology, Northwestern Uni- 
versity Medical School, Chicago. Handsome octavo of 547 pages, 
illustrated, including two full-page plates in colors. Cloth, ;^3.50 net. 

INCLUDING TOPOGRAPHIC ANATOMY 

This volume presents diseases of the Nose, Pharynx, and Ear as the author 
has seen them during an experience of nearly twenty-five years. In it are 
answered in detail those questions regarding the course and outcome of diseases 
which cause the less experienced observer the most anxiety in an mdividual case. 
Topographic anatomy has been accorded liberal space. 

Pennsylvsoiia Medical JoumzJ 

"This is the most practical volume on the nose, pharynx, and ear that has appeared 
recently. ... It is exactly what the less experienced observer needs, as it avoids the confusion 
incident to a categorical statement of everybody's opinion." 

Kyle's 
Diseases of Nose and Throat 



Diseases of the Nose and Throat. By D. Braden Kyle, M. D., 
Professor of Laryngology in the Jefferson Medical College, Phila- 
delphia. Octavo, 797 pages; with 219 illustrations, 26 in colors. 
Cloth, ;^4.oo net; Half Morocco, ^5.50 net. 

THE NEW (4th) EDITION 

Four large editions of this excellent work fully testify to its practical value. 
In this edition the author has revised the text thoroughly, bringing it absolutely 
down to date. With the practical purpose of the book in mind, extended con- 
sideration has been given to treatment, each disease being considered in full, and 
definite courses being laid down to meet special conditions and symptoms. 
Pennsylvania Medical Journal 

" Dr. Kyle's crisp, terse diction has enabled the inclusion of all needful nose and throat 
knowledge in this book. The practical man, be he special or general, will not search in vaia 
for anything he needs." 



EYE, EAR, NOSE, AND THROAT. 



GET m. • THE NEW 

THE BEST t\ in C n C Si n STANDARD 

Illustrated Dictionary 

The New (5th) Edition— Adopted by U. S. Army 

The American Illustrated Medical Dictionary. A new and com- 
plete dictionary of the terms used in Medicine, Surgery, Dentistry, 
Pharmacy, Chemistry, and kindred branches; with over loo new and 
elaborate tables and many handsome illustrations. By W. A. Newman 
Borland, M. D., Editor of " The American Pocket Medical Diction- 
ary." Large octavo, nearly ^y6 pages, bound in full flexible leather. 
Price, ^4.50 net; with thumb index, ^5.00 net 

A KEY TO MEDICAL LITERATURE— WITH 2000 NEW TERMS 

This dictionary is the "new standard." It defines hundreds of the newest 
terms not defined in any other dictionary — bar none. These terms are hve, 
active words, taken right from modern medical hterature. 

Howeird A. Kelly, M. D., 

Professor of Gynecologic Surgery, Johns Hopkitis University, Baltimore 

"Dr. Dorland's Dictionary is admirable. It is so well gotten up and of such convenient 
size. No errors have been found in my use of it." 

Theobald's Prevalent Eye Diseases 



Prevalent Diseases of the Eye. By Samuel Theobald, M. D., 
Clinical Professor of Ophthalmology and Otology, Johns Hopkins 
University. Octavo of 5 50 pages, with 219 text-cuts and several colored 
plates. Cloth, ^4.50 net ; Half Morocco, ^6.00 net. 

THE PRACTITIONER'S OPHTHALMOLOGY 

With few exceptions all the works on diseases of the eye, although written 
ostensibly for the general practitioner, are in reality adapted only to the specialist ; 
but Dr. Theobald in his book has described very clearly and in detail those condi- 
tions, the diagnosis and treatment of which come within the province of the general 
practitioner. The therapeutic suggestions are concise, unequivocal, and specific. 
It is the one work on the Eye written particularly for the general practitioner. 

Charles A. Oliver, M.D., 

Clinical Professor of Ophthalmology, Woman s Medical College of Pennsylvania. 

" I feel I can conscientiously recommend it, not only to the general physician and medical 
student, for whom it is primarily written, but also to the experienced ophthalmologist. Most 
surely Dr. Theobald has accomplished his purpose." 



8 EYE, EAR, NOSE, AND THROAT. 

deSchweinitz and HoUoway on Pulsating Exoph- 
thalmos 

Pulsating Exophthalmos. An analysis of sixty-nine cases not pre- 
viously analyzed. By George E. deSchweinitz, M. D., and Thomas 
B. HoLLOWAY, M. D. Octavo of 125 pages. Cloth, ;^2.oo net. 

This monograph consists of an analysis of sixty-nine cases of this affection 
not previously analyzed. The therapeutic measures, surgical and otherwise, 
which have been employed are compared, and an endeavor has been made 
to determine from these analyses which procedures seem likely to prove of 
the greatest value. It is the most valuable contribution to ophthalmic liter- 
ature within recent years. 

British Medical Journal 

" The book deals very thoroughly with the whole subject and in it the most complete account of 
the disease will be found." 

Jackson on the Eye The New (2d) Edition 

A Manual of the Diagnosis and Treatment of Diseases of the 
Eye. By Edward Jackson, A. M., M. D., Professor of Ophthalmology, 
University of Colorado. i2mo volume of 615 pages, with 184 beautiful 
illustrations. Cloth, ^2.50 net. 

The Medical Record, New York 

" It is truly an admirable work. . . . Written in a clear, concise manner, it bears evidence of the 
author's comprehensive grasp of the subject. The term ' multum in parvo ' is an appropriate one to 
apply to this work." 

Grant on Face, Mouth, and Jaws 

A Text-Book of the Surgical Principles and Surgical Diseases 
of the Face, Mouth, and Jaws. For Dental Students. By H. Horace 
Grant, A. M., M. D., Professor of Surgery and of Clinical Surgery, 
Hospital College of Medicine, Louisville. Octavo of 231 pages, with 
68 illustrations. Cloth, $2.50 net. 

Friedrich and Curtis on Nose, Larynx, and Ear 

RhINOLOGY, LARYNGOLOGy, AND OtOLOGY, AND ThEIR SIGNIFICANCE 

IN General Medicine. By Dr. E. P. Friedrich, of Leipzig. Edited 
by H. HoLBROOK Curtis, M. D., Consulting Surgeon to the New York 
Nose and Throat Hospital. Octavo volume of 350 pages. Cloth, 
$2.50 net. 



URINE AND IMPOTENCE. 



Ogden on the Urine 



Clinical Examination of Urine and Urinary Diagnosis. A Clinical 
Guide for the Use of Practitioners and Students of Medicine and Sur- 
gery. By J. Bergen Ogden, M. D., Medical Chemist to the Metro- 
politan Life Insurance Company, New York. Octavo, 418 pages, 54 
text illustrations, and a number of colored plates. Cloth, 1^3.00 net. 

THE NEW (3d) EDITION 

In this edition the work has been brought absolutely down to the present day. 
Urinary examinations for purposes of life insurance have been incorporated, because 
a large number of practitioners are often called upon to make such analyses. 
Special attention has been paid to diagnosis by the character of the urine, the 
diagnosis of diseases of the kidneys and urinary passages ; an enumeration of t!ie 
prominent clinical symptoms of each disease ; and the peculiarities of the urine 
in certain general diseases. 

The Lancet, London 

" We consider this manual to have been well compiled; and the author's own experience, 
so clearly stated, renders the volume a useful one both for study and reference." 

Pilcher's 
Practical Cystoscopy 

Practical Cystoscopy. By Paul M. Pilcher, M. D., Consulting 
Surgeon to the Eastern Long Island Hospital. Octavo of 398 pages, 
with 233 illustrations, 29 in colors. Cloth, $5.50 net. 

JUST READY 

Cystoscopy is to-day the most practical manner of diagnosing and treating 
diseases of the bladder, ureters, kidneys, and prostate. To be properly equipped, 
therefore, you must have at your instant command the information this book gives 
you. It explains away all difficulty, telling you why you do not see something 
when something is there to see, and telling you Jiow to see it. All theory has 
been uncompromisingly eliminated, devoting every line to practical, needed- 
every-day facts, telling you how and when to use the cystoscope and catheter — 
telling you in a way to make you know. The work is complete in every detail, 
describing, and showing you by good illustrations, the types and construction of 
the instruments, their care, preparation for their use in the home and in your 
office, and — most important of all — the technic of actual application in the diag- 
nosis and treatment of diseases of the bladder, ureters, prostate, and kidneys. 



lo SAUiXDERS' BOOKS O.Y 



StelwagonV 
Diseases of the Skin 



A Treatise on Diseases of the 5kin. By Henry W. Stelwagon, 
M. D., Ph. D., Professor of Dermatology in the Jefferson JMedical 
College, Philadelphia. Octavo of 1195 pages, with 289 text-cuts and 
34 plates. Cloth, $6.00 net; Half Morocco, ,$7.50 net. 

THE NEW (5tli) EDITION 

The demand for five editions of this work in a period of five years indicates 
the practical character of the book. In this edition the articles on Frambesia, 
Oriental Sore, and other tropical diseases have been entirely rewritten. The new 
subjects include Verruga Peruana, Leukemia Cutis, INIeralgia Parsesthetica, Dhobie 
Itch, and Uncinarial Dermatitis. 

George T. Elliot, M. D., Professor of Dermatology^ Cornell University. 

" It is a book that I recommend to my class at Cornell, because for conservative judgment, 
for accurate observation, and for a thorough appreciation of the essential position of derma- 
tology, I think it holds first place." 



Schamber^*s Diseases gf the Skin 
and E^mptive Pevers 



Diseases of the Skin and the Eruptive Fevers. By Jay F. Schamberg, 
M. D. , Professor of Dermatology and the Infectious Eruptive Diseases, Philadel- 
phia Polyclinic. Octavo of 534 pages, illustrated. Cloth, S3. 00 net. 

THE CUTANEOUS MANIFESTATIONS OF ALL DISEASES 

" The acute eruptive fevers constitute a valuable contribution, the statements made 
emanating from one who has studied these diseases in a practical and thorough manner from 
the standpoint of cutaneous medicine. . . . The views expressed on all topics are con- 
servative, safe to follow, and practical, and are well abreast of the knowledge of the present 
time, both as to general and special pathology, etiology, and treatment." — American Joumcu 
«/ Medical Sciences. 



GEXITO-URIXARY AXD XOSE, THROAT, ETC. ii 

Greene and Brooks' 
Genito-Urinary Diseases 

Diseases of the Genito=Urinary Organs and the Kidney. By 

Robert H. Greene, M. D., Professor of Genito-Urinar}- Surger\' at 
Fordham University ; and Harlow Brooks, M. D., Assistant Pro- 
fessor of Clinical ]\Iedicine, University and Bellevue Hospital ^ledical 
School. Octavo of 605 pages, illustrated. Cloth, S5.00 net; Half 
Morocco, $6.50 net 

THE NEW 2d EDITION 

This new work presents both the medical and surgical sides. Designed as a 
work of quick reference, it has been written in a clear, condensed style, so that 
the information can be readily grasped and retained. Kidfiey diseases are very 
elaborately detailed. 

New York MediceJ Joumed 

" As a whole the book is one of the most satisfactory and Tiseful works on genito-urinary 
diseases now extant, and will undoubtedly be popular among practitioners and students."' 

Gleason on Nose, Throat, 
and Ear 

A Manual of Diseases of the Nose, Throat, and Ear. By E. 

Baldwin Gleason, ^I. D., LL. D.. Clinical Professor of Otology, 
Medico-Chirurgical College, Philadelphia. i2mo of 556 pages, pro- 
fusely illustrated. Flexible leather, $2.50 net. 

THE NEW 2d) EDITION 

Methods of treatment have been simplified as much as possible, so that in 
most instances only those methods, drugs, and operations have been advised 
which have proved beneficial. A valuable feature consists of the collection of 
formulas. 

American JoumaJ of the Mediced Sciences 

" For the practitioner who wishes a reliable guide in laryngology and otology there are few 
books which can be more heartily commended." 



American Text-Book of Genito-Urinary Diseases, Syphilis, and 

Diseases of the 5kin. Edited by L. Bolton Bangs. M. D.. and 
W. A. Hardaway, M. D. Octavo, 1229 pages, 300 engravings, 20 
colored plates. Cloth, ^7.00 net. 



12 SAUNDERS* BOOKS ON 

Holland's Medical 
Chemistr y and To xicology 

A Text=Book of Medical Chemistry and Toxicology. By James 
W. Holland, M.D., Professor of Medical Chemistry and Toxicology, 
and Dean, Jefferson Medical College, Philadelphia. Octavo of 655 
pages, fully illustrated. Cloth, $3.00 net. 

THE NEW (2d) EDITION 

Dr. Holland's work is an entirely new one, and is based on his forty years* 
practical experience in teaching chemistry and medicine. It has been subjected to 
a thorough revision, and enlarged to the extent of some sixty pages. The additions 
to be specially noted are those relating to the electronic theory, chemical equilib- 
rium, Kjeldahl's method for determining nitrogen, chemistry of foods and their 
changes in the body, synthesis of proteins, and the latest improvements in urinary 
tests. More space is given to toxicology than in any other text-book on chemistry. 

American Medicine 

" Its statements are clear and terse ; its illustrations well chosen ; its development logical, 
systematic, and comparatively easy to follow. . . . We heartily commend the work." 

Grtinwald and Newcomb's 
Mouth, Pharynx, and Nose 

Atlas and Epitome of Diseases of the Mouth, Pharynx, and 
Nose. By Dr. L. Grunwald, of Munich. From the Second Revised 
and Enlarged German Edition. Edited, with additions, by James E. 
Newcomb, M. D., Instructor in Laryngology, Cornell University Medical 
School. With 102 illustrations on 42 colored lithographic plates, 41 
text-cuts, and 219 pages of text. Cloth, ;^3.oo net. In Saunders* 
Hand-Atlas Series. 

INCLUDING ANATOMY AND PHYSIOLOGY 

In designing this atlas the needs of both student and practitioner were kept 
constantly in mind, and as far as possible typical cases of the various diseases 
were selected. The illustrations are described in the text in exactly the same way 
as a practised examiner would demonstrate the objective findings to his class. 
The illustrations themselves are numerous and exceedingly well executed. The 
editor has incorporated his own valuable experience, and has also included exten- 
sive notes on the use of the active principle of the suprarenal bodies. 

Americem Medicine 

" Its conciseness without sacrifice of clearness and thoroughness, as well as the excellence 
of text and illustrations, are commendable." 



PISE AS ES OF THE SKIN. 13 

Mracek and Stelwagon's 
Diseases of the Skin 

Atlas and Epitome of Diseases of the Skin. By Prof. Dr. Franz 
Mracek, of Vienna. Edited, with additions, by Henry W. Stelwagon, 
M. D., Professor of Dermatology in the Jefferson Medical College, 
Philadelphia. With yj colored plates, 50 half-tone illustrations, and 
280 pages of text. I?i Saimders^ Ha7id-Atlas Series. Clo., S4.oonet 

THE NEW (2d) EDITION 

This volume, the outcome of years of scientific and artistic work, contains, 
together N^-ith colored plates of unusual beaut\-, numerous illustrations in black, 
and a text comprehending the entire field of dermatology. The illustrations are 
all original and prepared from actual cases in Mracek' s clinic, and the execution 
of the plates is superior to that of any, even the most expensive, dermatologic 
atlas hitherto published. 

American JoumeJ of the MediceJ Sciences 

■• The advantages which we see in this book and which recommend it to our minds are : 
First, its handiness ; secondly, the plates, which are excellent as regards drawing, color, and the 
diagnostic points which they bring out." 

Mracek anb Bangs' 
Syphilis and Venereal 

Atlas and Epitome of Syphilis and the Venereal Diseases. 

By Prof. Dr. Franz Mracek, of Vienna. Edited, with additions, by 
L. Bolton Bangs, M. D., late Prof, of Genito-Urinary Surgen% Univer- 
sity and Bellevue Hospital IMedical College, New York. With 71 
colored plates and 122 pages of text. Cloth, 33-50 net. In Satindcrs 
Ha?id- Atlas Series. 

CONTAINING 71 COLORED PLATE:S 

According to the unanimous opinion of numerous authorities, to whom the 
original illustrations of this book were presented, they surpass in beauty anything 
of the kind that has been produced in this field, not only in Germany, but 
throughout the literature of the world. 

Robert L. Dickinson, M.D., 

Art Editor of " Thi Anurican Text-Book of Obstetrics." 
" The book that appeals instantly to me for the strikingly successful, valuable, and graphic 
character of its illustrations is the ' Atlas of Syphilis and the Venereal Diseases.' I know of 
nothing in this country that can compare with it." 



14 SAUNDERS' BOOKS ON 

Wells* Chemical Pathology 

Chemical Pathology. Being a discussion of General Path- 
ology from the Standpoint of the Chemical Processes Involved. 
By H. Gideon Wells, Ph. D., M. D., Assistant Professor of 
Pathology in the University of Chicago. Octavo of 549 pages. 
Cloth, ^^3.25 net; Half Morocco, ;$4.75 net. 

Dr. Wells here concisely presents the latest work systematically con- 
sidering the subject of general pathology from the standpoint of the chemical 
processes involved. Special chapters are' devoted to Diabetes and to Uric- 
acid Metabolism and Gout. 

Wm. H. Welch, M. D., Professor of Pathology, Johtis Hopkins University. 

" The work fills a real need in the English literature of a very important subject, and 
I shall be glad to recommend it to my students." 



The New (2d) Edition 



Saxe's Urinalysis 

Examination of the Urine. By G. A. De Santos Saxe, M. D., 
Instructor in Genito-Urinary Surgery, York Post-graduate Medical 
School and Hospital. i2mo of 448 pages, fully illustrated. 
Cloth, 31.75 net. 

This work is intended as an aid in diagnosis, by interpreting the clinical 
significance of the chemic and microscopic urinary findings. 

Francis Cetrter Wood, M. D,, Adjunct Professor of Clinical Pathology, Columbia Uni- 
versity. 

"It seems to me to be one of the best of the smaller works on this subject ; it is, 
indeed, better than a good many of the larger ones." 

deSchweinitz and Randall on the £ye» £ar» 
Nose, and Throat 

American Text-Book of Diseases of the Eye, Ear, Nose, and 
Throat. Edited by G. E. de Schweinitz, M. D., Professor of 
Ophthalmology in the University of Pennsylvania ; and B. Alex- 
ander Randall, M. D., Clinical Professor of Diseases of the Ear 
in the University of Pennsylvania. Imperial octavo, 125 1 pages, 
with 766 illustrations, 59 of them in colors. Cloth, ^7.00 net; 
Half Morocco, ;^8.50 net. 

Grunwald and Grayson on the Larynx 

Atlas and Epitome of Diseases of the Larynx. By Dr. L. 

Grunwald, of Munich. Edited, with additions, by Charles P. 
Grayson, M. D., Clinical Professor of Laryngolog}^ and Rhinology, 
University of Pennsylvania. With 107 colored figures on 44 
plates, 25 text-cuts, and 103 pages of text. Cloth, $2.^0 net. 
In Saunders' Hand-Atlas Series. 



CHEMISTRY, SKIN, AND VENEREAL DISEASES. \^ 

American Pocket Dictionary sixth Edition 

The American Pocket Medical Dictionary. Edited by W. A 
Newman Borland, M. D., Editor " American Illustrated Medical 
Dictionary." Containing- the pronunciation and definition of the 
principal words used in medicine and kindred sciences. 598 pages. 
Flexible leather, with gold edges, ;^i.oo net; with thumb index, 
$1.2^ net. 
James W. Holland. M. D.. 

Professor of Medical Chemistry and Toxicology, and Dean, Jefferson Medical College 
Philadelphia, '^ ' 

" I am struck at once with admiration at the compact size and attractive exterior. ] 
can recommend it to our students without reserve." 

Stelwagon's Essentials of Skin 7th Edition 

Essentials of Diseases of the Skin. By Henry W. Stel- 
wagon, M. D., Ph.D., Professor of Dermatology in the Jeffer- 
son Medical College, Philadelphia. Post-octavo of 291 pages, 
with 72 text-illustrations and 8 plates. Cloth, ;^i.oo net. In 
Saunders' Question- Compend Series, 
The Medical News 

" In line with our present knowledge of diseases of the skin. . . . Continues to main- 
tain the high standard of excellence for which these question compends have been noted." 

Wolffs Medical Chemistry New (7th) Edition 

Essentials of Medical Chemistry, Organic and Inorganic. 
Containing also Questions on Medical Physics, Chemical Physiol- 
ogy, Analytical Processes, Urinalysis, and Toxicology. By Law- 
rence Wolff, M. D., Late Demonstrator of Chemistry, Jefferson 
Medical College. Revised by A. Ferree Wither, Ph. G., M. D., 
Formerly Assistant Demonstrator of Physiology, University of 
Pennsylvania. Post-octavo of 222 pages. Cloth, ^i.oo net. /// 
Saunders' Question- Compend Series. 

Martin's Minor Surgery, Bandaging, and the Venereal 

Diseases second Edition, Revised 

Essentials of Minor Surgery, Bandaging, and Venereal 
Diseases. By Edward Martin, A. M., M. D., Professor of Clin- 
ical Surgery, University of Pennsylvania, etc. Post-octavo, 166 
pages, with 78 illustrations. Cloth, ^i.oo net. I?t Saunders' 
Question- Compend Series. 

Vecki's Sexual Impotence Third Edition 

The Pathology and Treatment of Sexual Impotence. By 
Victor G. Vecki, M. D. From the Second Revised and Enlarged 
German Edition. i2mo volume of 339 pages. Cloth, ;^2.oo net. 

Johns Hopkins Hospital Bulletin 

" A scientific treatise upon an important and much neglected subject. . . . The 
treatment of impotence in general and of sexual neurasthenia is discriminating and 
judicious." 



i6 URINE, EYE, EAR, NOSE, AND THROAT. 

Wolfs Examination of Urine 

A Laboratory Handbook of Physiologic Chemistry and 
Urine-examination. By Charles G. L. Wolf, M. D., Instructor in 
Physiologic Chemistry, Cornell University Medical College, New 
York. i2mo volume of 204 pages, fully illustrated. Cloth, ;^i.25 net. 
British Medical Journal 

" The methods of examining the urine are very fully described, and there are at the 
end of the book some extensive tables drawn up to assist in urinary diagnosis." 

Jackson's Essentials of Eye Third Revised Edition 

Essentials of Refraction and of Diseases of the Eye. By 
Edward Jackson, A. M., M. D., Emeritus Professor of Diseases of 
the Eye, Philadelphia Polyclinic. Post-octavo of 261 pages, 82 illus- 
trations. Cloth, ^i.oo net. In Saunders' Question- Comp end Series. 
Johns Hopkins Hospital Bulletin 

" The entire ground is covered, and the points that most need careful elucidation 
are made clear and easy." 

Gleason's Nose and Throat Fourth Edition. Revised 

Essentials of Diseases of the Nose and Throat, By E. B. 
Gleason, S. B., M. D., CHnical Professor of Otology, Medico- 
Chirurgical College, Philadelphia, etc. Post-octavo, 241 pages, 1 12 
illustrations. Cloth, ^i.oo net. In Saunders' Question Compends, 
The Lancet, London 

" The careful description which is given of the various procedures would be sufficient 
to enable most people of average intelligence and of slight anatomical knowledge to 
make a very good attempt at laryngoscopy." 

Gleason's Diseases of the Ear Third Edition, Revised 

Essentials of Diseases of the Ear. By E. B. Gleason, S. B., 
M. D., CHnical Professor of Otology, Medico-Chirurgical College, 
Phila., etc. Post-octavo volume of 214 pages, with 114 illustra- 
tions. Cloth, ;^ I. GO net. In Saunders' Question- Compend Series. 
Bristol Medico-Chirurgical Journal 

"We know of no other small work on ear diseases to compare with this, either in 
freshness of style or completeness of information." 

l^ilcox on Genito-Urinary and Venereal Diseases 

The New (2d) Edition 

Essentials of Genito-Urinary and Venereal Diseases. By 
Starling S. Wilcox, M. D., Lecturer on Genito-Urinary Diseases 
and Syphilology, Starling-Ohio Medical College, Columbus. i2mo 
of 321 pages, illustrated. Cloth, ^^i.oo net. Saunders' Compends, 

Stevenson's Photoscopy \jyi . 

Photoscopy (Skiascopy or Retinoscop\j^ By Mark D. Stev- 
enson, M. D., Ophthalmic Surgeon to theji^kron City Hospital. 
i2mo of 126 pages, illustrated. ^ Cloth, $\.2^ net. 

Edward Jackson, M. D., University of Colorado. *^ 

" It is well written and will prove a valuable help. You|u.treatment of the emergent 
pencil of rays, and the part falling on the examiner's eye, is decidedly better than any 
previous account." ,^ 










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